{"hospital_name":"RIO GRANDE REGIONAL HOSPITAL","last_updated_on":"2026-03-01","version":"3.0.0","location_name":["ER 24/7 MCALLEN","ER 24/7 MISSION","RIO GRANDE REGIONAL HOSPITAL","ER 24/7 EDINBURG","ER 24/7 SAN JUAN"],"hospital_address":["5100 W EXPRESSWAY 83, MCALLEN, TX, 78501","102 W GRIFFIN PKWY, MISSION, TX, 78572","101 EAST RIDGE ROAD, MCALLEN, TX, 78503","2744 W UNIVERSITY DRIVE, EDINBURG, TX, 78539","200 E EXPRESSWAY 83, SAN JUAN, TX, 78589"],"license_information":{"license_number":"601","state":"TX"},"type_2_npi":["1619924719"],"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":"Laura Disque"},"standard_charge_information":[{"description":"Preparation of fecal microbiota for instillation, including assessment of donor specimen ","code_information":[{"code":"362","type":"RC"},{"code":"44705","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bypass graft, with other than vein; axillary-femoral ","code_information":[{"code":"35621","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":14806.470,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10801.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":13181.640,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":13181.640,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13994.060,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14806.470,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Gastrojejunostomy; 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":521.990,"methodology":"fee schedule"}]}]},{"description":"Injection, pemetrexed ditromethamine, 10 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J9323","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.210,"maximum":0.210,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.210,"methodology":"fee schedule"}]}]},{"description":"Incision and drainage, complex, postoperative 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may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":5797.220,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6098.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health 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The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Gradient compression garment, neck/head, each ","code_information":[{"code":"A6566","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":249.660,"maximum":619.040,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":256.920,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":254.750,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":267.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":334.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":409.410,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":409.410,"methodology":"fee 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"}]}]},{"description":"INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC ","code_information":[{"code":"120","type":"RC"},{"code":"387","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Bone graft, femoral head, neck, intertrochanteric or subtrochanteric area (includes obtaining bone graft) ","code_information":[{"code":"27170","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15771.790,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11505.850,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14041.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14041.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14906.410,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15771.790,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"}]}]},{"description":"DENTAL AND ORAL DISEASES WITH CC 4 Day Stay","code_information":[{"code":"123","type":"RC"},{"code":"158","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC 2 Day Stay","code_information":[{"code":"113","type":"RC"},{"code":"557","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"126","type":"RC"},{"code":"282","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"SPLENIC PROCEDURES WITH MCC ","code_information":[{"code":"135","type":"RC"},{"code":"799","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Endoscopic cannulation of papilla with direct visualization of pancreatic/common bile duct(s) (List separately in addition to code(s) for primary procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"43273","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1672.000,"maximum":13370.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":9999.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":11331.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":13370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC 3 Day Stay","code_information":[{"code":"021","type":"MS-DRG"},{"code":"142","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Vestibular nerve section, translabyrinthine approach ","code_information":[{"code":"490","type":"RC"},{"code":"69915","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4950.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6181.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6181.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6548.230,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6888.730,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7577.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8586.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":10131.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":951.370,"methodology":"fee schedule"}]}]},{"description":"Tenolysis, flexor or extensor tendon, leg and/or ankle; 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WITH 2 Day Stay","code_information":[{"code":"158","type":"RC"},{"code":"409","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Bypass graft, with vein; tibial-tibial, peroneal-tibial, or tibial/peroneal trunk-tibial ","code_information":[{"code":"35570","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":20393.310,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":14877.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":18155.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":18155.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":19274.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20393.310,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"MAJOR BLADDER PROCEDURES WITH MCC ","code_information":[{"code":"145","type":"RC"},{"code":"653","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"RECTAL RESECTION WITH MCC ","code_information":[{"code":"122","type":"RC"},{"code":"332","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"EXTRACRANIAL PROCEDURES WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"039","type":"MS-DRG"},{"code":"140","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with strain imaging ","code_information":[{"code":"349","type":"RC"},{"code":"C9762","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":426.360,"maximum":426.360,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":426.360,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed ","code_information":[{"code":"310","type":"RC"},{"code":"87522","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":36.710,"maximum":149.120,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":149.120,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":149.120,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":36.710,"methodology":"fee schedule"}]}]},{"description":"Insertion of pacemaker pulse generator only; with existing multiple leads ","code_information":[{"code":"33221","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":48163.770,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":34611.990,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":43219.200,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":43219.200,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":45783.050,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":48163.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":46963.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":10589.270,"methodology":"fee schedule"}]}]},{"description":"Tracheostomy, fenestration procedure with skin flaps ","code_information":[{"code":"31610","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3041.000,"maximum":12756.890,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9167.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11447.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11447.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12126.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12756.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; Pneumocystis carinii ","code_information":[{"code":"311","type":"RC"},{"code":"87281","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.260,"maximum":41.740,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":41.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":41.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":10.260,"methodology":"fee schedule"}]}]},{"description":"EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 4 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"982","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Removal by contouring of benign tumor of facial bone (eg, fibrous dysplasia) ","code_information":[{"code":"21029","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12635.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1119.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4950.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6181.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6181.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6548.230,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6888.730,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":951.370,"methodology":"fee schedule"}]}]},{"description":"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WIT 4 Day Stay","code_information":[{"code":"151","type":"RC"},{"code":"562","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"TRAUMATIC INJURY WITH MCC 2 Day Stay","code_information":[{"code":"131","type":"RC"},{"code":"913","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"PROSTATIC WATER THERMOTHER ","code_information":[{"code":"369","type":"RC"},{"code":"53853","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WI ","code_information":[{"code":"023","type":"MS-DRG"},{"code":"150","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"MAJOR CHEST PROCEDURES WITH CC 4 Day Stay","code_information":[{"code":"164","type":"MS-DRG"},{"code":"164","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Intestinal allotransplantation; from living donor ","code_information":[{"code":"44136","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":46648.570,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":34031.110,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":41529.480,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":41529.480,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":44089.030,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":46648.570,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Hmatrix, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"892","type":"RC"},{"code":"Q4134","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"OTITIS MEDIA AND URI WITHOUT MCC 3 Day Stay","code_information":[{"code":"148","type":"RC"},{"code":"153","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); ","code_information":[{"code":"25120","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15410.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1373.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"Management of liver hemorrhage; complex suture of liver wound or injury, with or without hepatic artery ligation ","code_information":[{"code":"47360","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3061.000,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC ","code_information":[{"code":"147","type":"RC"},{"code":"832","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s) ","code_information":[{"code":"409","type":"RC"},{"code":"72142","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":293.440,"maximum":978.700,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":978.700,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":978.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":293.440,"methodology":"fee schedule"}]}]},{"description":"Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple ","code_information":[{"code":"367","type":"RC"},{"code":"43261","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":5487.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"120","type":"RC"},{"code":"909","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"MASTECTOMY FOR MALIGNANCY WITH CC/MCC ","code_information":[{"code":"128","type":"RC"},{"code":"582","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each ","code_information":[{"code":"26755","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"GASTROINTESTINAL HEMORRHAGE WITH MCC 4 Day Stay","code_information":[{"code":"145","type":"RC"},{"code":"377","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"116","type":"RC"},{"code":"630","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Odontics repr abutment ","code_information":[{"code":"790","type":"RC"},{"code":"D6095","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MC ","code_information":[{"code":"141","type":"RC"},{"code":"739","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC 2 Day Stay","code_information":[{"code":"169","type":"RC"},{"code":"729","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"HYPERTENSION WITH MCC ","code_information":[{"code":"128","type":"RC"},{"code":"304","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC 2 Day Stay","code_information":[{"code":"124","type":"RC"},{"code":"758","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"131","type":"RC"},{"code":"615","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solut ","code_information":[{"code":"360","type":"RC"},{"code":"62327","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":365.660,"maximum":5841.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":430.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1534.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1916.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1916.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":2030.130,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2135.690,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2012.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2527.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2650.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2505.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":365.660,"methodology":"fee schedule"}]}]},{"description":"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC 2 Day Stay","code_information":[{"code":"025","type":"MS-DRG"},{"code":"110","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITH MCC 4 Day Stay","code_information":[{"code":"140","type":"RC"},{"code":"388","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Catheterization with removal of temporary device for ischemic remodeling (ie, pressure necrosis) of bladder neck and prostate ","code_information":[{"code":"369","type":"RC"},{"code":"53866","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":494.620,"maximum":3675.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":494.620,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":603.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":603.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":640.930,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":678.340,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"146","type":"RC"},{"code":"395","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"167","type":"RC"},{"code":"819","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, with free graft (includes obtaining graft), each tendon or muscle ","code_information":[{"code":"25274","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":8444.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tenodesis at wrist; extensors of fingers ","code_information":[{"code":"25301","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":15410.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"ASXL1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; full gene sequence ","code_information":[{"code":"303","type":"RC"},{"code":"81175","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":676.500,"maximum":1993.800,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1993.800,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1993.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":676.500,"methodology":"fee schedule"}]}]},{"description":"Bone graft with microvascular anastomosis; fibula ","code_information":[{"code":"20955","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2692.000,"maximum":5069.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5069.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3911.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3911.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3716.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4601.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2692.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITH MCC 2 Day Stay","code_information":[{"code":"080","type":"MS-DRG"},{"code":"158","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Isolation- tooth w rubb dam ","code_information":[{"code":"481","type":"RC"},{"code":"D3910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC ","code_information":[{"code":"099","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1275.000,"maximum":3060.000,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":1275.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3060.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $552131.00, reimbursement will be $6139 per diem instead of the contracted rate."}]}]},{"description":"Cystectomy, complete; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes ","code_information":[{"code":"499","type":"RC"},{"code":"51575","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":24604.370,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":17949.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":21904.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":21904.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":23254.370,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":24604.370,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"TRAUMATIC INJURY WITH MCC 4 Day Stay","code_information":[{"code":"134","type":"RC"},{"code":"913","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC Pediatric","code_information":[{"code":"133","type":"RC"},{"code":"468","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":36460.000,"maximum":48750.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":36460.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":41314.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":48750.000,"methodology":"case rate"}]}]},{"description":"Transplantation of pancreatic allograft ","code_information":[{"code":"48554","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":34462.970,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":25141.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":30681.100,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":30681.100,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":32572.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":34462.970,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC ","code_information":[{"code":"160","type":"RC"},{"code":"286","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC 4 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"267","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Injection, aflibercept hd, 1 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J0177","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":506.530,"maximum":506.530,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":506.530,"methodology":"fee schedule"}]}]},{"description":"OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC 3 Day Stay","code_information":[{"code":"139","type":"RC"},{"code":"357","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Cygnus disk, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"636","type":"RC"},{"code":"Q4362","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH MCC 2 Day Stay","code_information":[{"code":"116","type":"RC"},{"code":"299","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC ","code_information":[{"code":"148","type":"RC"},{"code":"578","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Implantation of absorbable mesh or other prosthesis for delayed closure of defect(s) (ie, external genitalia, perineum, abdominal wall) due to soft tissue infection or trauma ","code_information":[{"code":"15778","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":12018.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3892.020,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":4749.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":4749.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":5042.310,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5335.030,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"DYSEQUILIBRIUM ","code_information":[{"code":"149","type":"MS-DRG"},{"code":"149","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC ","code_information":[{"code":"124","type":"RC"},{"code":"234","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. 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"}]}]},{"description":"Repair blood vessel with vein graft; intrathoracic, without bypass ","code_information":[{"code":"35246","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":21106.820,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":15397.870,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":18790.620,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":18790.620,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":19948.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":21106.820,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"In-situ vein bypass; popliteal-tibial, peroneal ","code_information":[{"code":"35587","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":18425.270,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":13441.620,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":16403.330,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":16403.330,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":17414.300,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":18425.270,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Clotting; factor VIII, VW factor antigen ","code_information":[{"code":"306","type":"RC"},{"code":"85246","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.660,"maximum":79.860,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":79.860,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":79.860,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":22.940,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":19.660,"methodology":"fee schedule"}]}]},{"description":"Excision external ear; complete amputation ","code_information":[{"code":"362","type":"RC"},{"code":"69120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":5487.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry calculation(s) ","code_information":[{"code":"322","type":"RC"},{"code":"77306","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":459.570,"maximum":459.570,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":459.570,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":459.570,"methodology":"fee schedule"}]}]},{"description":"Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrangements, aneuploidy, and ","code_information":[{"code":"0553U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":759.050,"maximum":759.050,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":759.050,"methodology":"fee 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","code_information":[{"code":"324","type":"RC"},{"code":"76932","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":310.560,"maximum":310.560,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":310.560,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":310.560,"methodology":"fee schedule"}]}]},{"description":"Removal of total disc arthroplasty, (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure) ","code_information":[{"code":"0164T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1672.000,"maximum":13988.660,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10205.020,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12453.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12453.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13221.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13988.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 2 Day Stay","code_information":[{"code":"153","type":"RC"},{"code":"345","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITH CC 2 Day Stay","code_information":[{"code":"119","type":"RC"},{"code":"389","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES ","code_information":[{"code":"125","type":"RC"},{"code":"776","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITH MCC 3 Day Stay","code_information":[{"code":"080","type":"MS-DRG"},{"code":"156","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WIT 3 Day Stay","code_information":[{"code":"123","type":"RC"},{"code":"496","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace (List separately in addition to code for primary procedure ","code_information":[{"code":"63076","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2692.000,"maximum":5069.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5069.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3911.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3911.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3716.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4601.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2692.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk ","code_information":[{"code":"362","type":"RC"},{"code":"G0121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":5487.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WIT 2 Day Stay","code_information":[{"code":"159","type":"RC"},{"code":"495","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Placement of amniotic membrane on the ocular surface; without sutures ","code_information":[{"code":"65778","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1525.170,"maximum":5487.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1525.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1904.450,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1904.450,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":2017.430,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2122.330,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2527.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2650.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"}]}]},{"description":"APPLICATION OF BODY CAST ","code_information":[{"code":"29020","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"Urography, retrograde, with or without KUB ","code_information":[{"code":"614","type":"RC"},{"code":"74420","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":78.730,"maximum":78.730,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":78.730,"methodology":"fee schedule"}]}]},{"description":"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES ","code_information":[{"code":"147","type":"RC"},{"code":"844","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC ","code_information":[{"code":"122","type":"RC"},{"code":"469","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"MINOR SKIN DISORDERS WITH MCC ","code_information":[{"code":"125","type":"RC"},{"code":"606","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITH MCC ","code_information":[{"code":"101","type":"RC"},{"code":"444","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Closed treatment of patellar dislocation; requiring anesthesia ","code_information":[{"code":"27562","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":91.560,"maximum":5841.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":407.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":508.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":508.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":539.100,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":567.130,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2527.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2650.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":91.560,"methodology":"fee schedule"}]}]},{"description":"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC ","code_information":[{"code":"136","type":"RC"},{"code":"628","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"BONE DISEASES AND ARTHROPATHIES WITH MCC Pediatric","code_information":[{"code":"203","type":"RC"},{"code":"553","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17076.000,"maximum":22832.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":17076.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":19349.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22832.000,"methodology":"case rate"}]}]},{"description":"Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study ","code_information":[{"code":"921","type":"RC"},{"code":"93926","type":"CPT"},{"code":"939261","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":111.150,"maximum":111.150,"gross_charge":2010.50,"discounted_cash":2010.50,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":111.150,"methodology":"fee schedule"}]}]},{"description":"Manipulation, wrist, under anesthesia ","code_information":[{"code":"25259","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MC 2 Day Stay","code_information":[{"code":"158","type":"RC"},{"code":"517","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Removal of embedded foreign body, vestibule of mouth; simple ","code_information":[{"code":"40804","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1485.390,"maximum":5841.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1485.390,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1854.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1854.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1964.800,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2066.970,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"}]}]},{"description":"Excision of penile plaque (Peyronie disease); with graft to 5 cm in length ","code_information":[{"code":"54111","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1812.830,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":7997.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":9986.620,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":9986.620,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":10579.050,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11129.160,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1812.830,"methodology":"fee schedule"}]}]},{"description":"Serum screening for cytotoxic percent reactive antibody (PRA); standard method ","code_information":[{"code":"319","type":"RC"},{"code":"86807","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":67.390,"maximum":221.790,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":221.790,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":221.790,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":67.390,"methodology":"fee schedule"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"122","type":"RC"},{"code":"833","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"AICD GENERATOR PROCEDURES ","code_information":[{"code":"112","type":"RC"},{"code":"245","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC ","code_information":[{"code":"146","type":"RC"},{"code":"337","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"MEDICAL BACK PROBLEMS WITHOUT MCC Pediatric","code_information":[{"code":"552","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15708.550,"maximum":20198.190,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":15708.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":17665.170,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":17665.170,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":18932.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20198.190,"methodology":"fee schedule"}]}]},{"description":"Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus ","code_information":[{"code":"490","type":"RC"},{"code":"64680","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":365.660,"maximum":7227.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1534.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1916.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1916.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":2030.130,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2135.690,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2012.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2505.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":365.660,"methodology":"fee schedule"}]}]},{"description":"Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endogra ","code_information":[{"code":"34843","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3061.000,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC 4 Day Stay","code_information":[{"code":"100","type":"RC"},{"code":"462","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"148","type":"MS-DRG"},{"code":"158","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"PNEUMOTHORAX WITH CC 3 Day Stay","code_information":[{"code":"158","type":"RC"},{"code":"200","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC ","code_information":[{"code":"128","type":"RC"},{"code":"146","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"151","type":"RC"},{"code":"743","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Surgery of intracranial arteriovenous malformation; dural, simple ","code_information":[{"code":"61690","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":29692.250,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":21661.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":26433.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":26433.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":28063.080,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":29692.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"MALIGNANT BREAST DISORDERS WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"167","type":"RC"},{"code":"599","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC 2 Day Stay","code_information":[{"code":"040","type":"MS-DRG"},{"code":"112","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Portoenterostomy (eg, Kasai procedure) ","code_information":[{"code":"361","type":"RC"},{"code":"47701","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":23112.130,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":16860.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":20575.870,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":20575.870,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":21844.000,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":23112.130,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"SKIN ULCERS WITH MCC ","code_information":[{"code":"147","type":"RC"},{"code":"592","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Closed treatment of fracture great toe, phalanx or phalanges; with manipulation ","code_information":[{"code":"28495","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":91.560,"maximum":5841.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":107.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":648.310,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":791.050,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":791.050,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":840.080,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":889.110,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":91.560,"methodology":"fee schedule"}]}]},{"description":"OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC 3 Day Stay","code_information":[{"code":"146","type":"RC"},{"code":"229","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Excision, coccygeal pressure ulcer, with coccygectomy; with primary suture ","code_information":[{"code":"15920","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":874.740,"maximum":7037.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4382.700,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":5472.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":5472.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":5797.220,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6098.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":874.740,"methodology":"fee schedule"}]}]},{"description":"CORONARY BYPASS WITH PTCA WITHOUT MCC Pediatric","code_information":[{"code":"153","type":"RC"},{"code":"232","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":108969.000,"maximum":145704.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":108969.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":123478.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":145704.000,"methodology":"case rate"}]}]},{"description":"Removal of wrist prosthesis; 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"}]}]},{"description":"SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC 3 Day Stay","code_information":[{"code":"149","type":"RC"},{"code":"451","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Revision of colostomy; simple (release of superficial scar) (separate procedure) ","code_information":[{"code":"362","type":"RC"},{"code":"44340","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"RADIOTHERAPY ","code_information":[{"code":"149","type":"RC"},{"code":"849","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Arteriovenous anastomosis, open; by upper arm basilic vein transposition ","code_information":[{"code":"36819","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2080.790,"maximum":12087.980,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8686.800,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":10847.010,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":10847.010,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":11490.470,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12087.980,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5851.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2080.790,"methodology":"fee schedule"}]}]},{"description":"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC 2 Day Stay","code_information":[{"code":"146","type":"RC"},{"code":"625","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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"}]}]},{"description":"Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, any method, under fluoroscopic guidance including cont ","code_information":[{"code":"49460","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":359.420,"maximum":5055.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1485.390,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1854.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1854.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1964.800,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2066.970,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2251.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2527.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2650.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":359.420,"methodology":"fee schedule"}]}]},{"description":"Thromboendarterectomy, including patch graft, if performed; 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"}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC ","code_information":[{"code":"10D07Z3","type":"ICD"},{"code":"151","type":"RC"},{"code":"806","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1422.000,"maximum":2678.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":2678.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1964.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":2433.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1422.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "}]}]},{"description":"Hematology (autosomal dominant congenital thrombocytopenia), genomic sequence analysis of 14 genes, blood, buccal swab, or amniotic fluid ","code_information":[{"code":"0269U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":608.170,"maximum":608.170,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":608.170,"methodology":"fee schedule"}]}]},{"description":"Debridement of extensive eczematous or infected skin; each additional 10% of the body surface, or part thereof (List separately in addition to code for primary procedure) ","code_information":[{"code":"11001","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC ","code_information":[{"code":"141","type":"RC"},{"code":"511","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"MAJOR ESOPHAGEAL DISORDERS WITH MCC ","code_information":[{"code":"160","type":"RC"},{"code":"368","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"PENIS PROCEDURES WITH CC/MCC ","code_information":[{"code":"101","type":"RC"},{"code":"709","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC 2 Day Stay","code_information":[{"code":"123","type":"RC"},{"code":"754","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique ","code_information":[{"code":"304","type":"RC"},{"code":"87529","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30.070,"maximum":122.190,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":122.190,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":122.190,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":30.070,"methodology":"fee schedule"}]}]},{"description":"Insulin; free ","code_information":[{"code":"311","type":"RC"},{"code":"83527","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.100,"maximum":45.060,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":45.060,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":45.060,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":11.100,"methodology":"fee schedule"}]}]},{"description":"Resection and repair of portion of bronchus (bronchoplasty) when performed at time of lobectomy or segmentectomy (List separately in addition to code for primary procedure) ","code_information":[{"code":"32501","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER O.R. PROCEDURES FOR INJURIES WITH MCC ","code_information":[{"code":"138","type":"RC"},{"code":"907","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Insertion by physician or other qualified health care professional of sphenoidal electrodes for electroencephalographic (EEG) recording ","code_information":[{"code":"481","type":"RC"},{"code":"95830","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":898.120,"maximum":1231.110,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":898.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1096.010,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1096.010,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1163.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1231.110,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC ","code_information":[{"code":"137","type":"RC"},{"code":"268","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Proton treatment delivery; simple, without compensation ","code_information":[{"code":"343","type":"RC"},{"code":"77520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2431.800,"maximum":2431.800,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":2431.800,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":2431.800,"methodology":"fee schedule"}]}]},{"description":"FOOT PROCEDURES WITH CC ","code_information":[{"code":"159","type":"RC"},{"code":"504","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments ","code_information":[{"code":"22800","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":18346.070,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":13383.840,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":16332.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":16332.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":17339.450,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":18346.070,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16496.000,"methodology":"case rate"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. 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"}]}]},{"description":"SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS ","code_information":[{"code":"029","type":"MS-DRG"},{"code":"149","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"152","type":"RC"},{"code":"379","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Biopsy of anorectal wall, anal approach (eg, congenital megacolon) ","code_information":[{"code":"45100","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1008.590,"maximum":6165.190,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4430.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":5532.260,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":5532.260,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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"}]}]},{"description":"COMPLICATIONS OF TREATMENT WITH CC 4 Day Stay","code_information":[{"code":"152","type":"RC"},{"code":"920","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC ","code_information":[{"code":"243","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13951.190,"maximum":13951.190,"payers_information":[{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":13951.190,"methodology":"fee schedule"}]}]},{"description":"ANGINA PECTORIS 2 Day Stay","code_information":[{"code":"118","type":"RC"},{"code":"311","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC ","code_information":[{"code":"131","type":"RC"},{"code":"271","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"CONNECTIVE TISSUE DISORDERS WITH CC ","code_information":[{"code":"143","type":"RC"},{"code":"546","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. 2 Day Stay","code_information":[{"code":"142","type":"RC"},{"code":"826","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Alveoloplasty w/extract 1-3 ","code_information":[{"code":"481","type":"RC"},{"code":"D7311","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC 3 Day Stay","code_information":[{"code":"097","type":"MS-DRG"},{"code":"129","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"DENTAL AND ORAL DISEASES WITH CC 2 Day Stay","code_information":[{"code":"150","type":"RC"},{"code":"158","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"137","type":"RC"},{"code":"819","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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autologous transplantation ","code_information":[{"code":"38241","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":605.860,"maximum":8328.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2501.640,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3123.740,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3123.740,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3309.050,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3481.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":605.860,"methodology":"fee schedule"}]}]},{"description":"Assistive algorithmic electrocardiogram risk-based assessment for cardiac dysfunction (eg, low-ejection fraction, pulmonary hypertension, hypertrophic cardiomyopathy); related to concurrently performe ","code_information":[{"code":"0764T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MC 2 Day Stay","code_information":[{"code":"153","type":"RC"},{"code":"517","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WI ","code_information":[{"code":"024","type":"MS-DRG"},{"code":"167","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Cystourethroscopy (including ureteral catheterization); with manipulation, without removal of ureteral calculus ","code_information":[{"code":"369","type":"RC"},{"code":"52330","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1226.380,"maximum":12635.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1442.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5705.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7123.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7123.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7546.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7938.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1226.380,"methodology":"fee schedule"}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"121","type":"RC"},{"code":"282","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC ","code_information":[{"code":"110","type":"RC"},{"code":"628","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"SEPTIC ARTHRITIS WITH MCC ","code_information":[{"code":"126","type":"RC"},{"code":"548","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), including all radiological supervision and interpretation, int ","code_information":[{"code":"490","type":"RC"},{"code":"61624","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":16496.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11468.470,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":13995.420,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":13995.420,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14857.980,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15720.550,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":9875.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16496.000,"methodology":"case rate"}]}]},{"description":"STRIP RETINAL MEMBRANE ","code_information":[{"code":"490","type":"RC"},{"code":"67038","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s) ","code_information":[{"code":"72147","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":291.060,"maximum":291.060,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":291.060,"methodology":"fee schedule"}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"125","type":"RC"},{"code":"759","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"MAJOR SKIN DISORDERS WITHOUT MCC ","code_information":[{"code":"164","type":"RC"},{"code":"596","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC ","code_information":[{"code":"067","type":"MS-DRG"},{"code":"153","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Inguinofemoral lymphadenectomy, superficial, including Cloquet's node (separate procedure) ","code_information":[{"code":"38760","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3041.000,"maximum":3041.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ACUTE LEUKEMIA WITH CC 2 Day Stay","code_information":[{"code":"147","type":"RC"},{"code":"835","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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"}]}]},{"description":"TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"143","type":"RC"},{"code":"714","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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"}]}]},{"description":"Excision, nasal polyp(s), extensive ","code_information":[{"code":"30115","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":5487.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"129","type":"RC"},{"code":"615","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH 2 Day Stay","code_information":[{"code":"129","type":"RC"},{"code":"408","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter over 4.0 cm ","code_information":[{"code":"17266","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":128.930,"maximum":5841.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":151.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":865.370,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1055.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1055.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1121.340,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1186.790,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health 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"}]}]},{"description":"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC ","code_information":[{"code":"156","type":"RC"},{"code":"441","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Salpingostomy (salpingoneostomy) ","code_information":[{"code":"362","type":"RC"},{"code":"58770","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC ","code_information":[{"code":"0D198ZB","type":"ICD"},{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":26065.000,"maximum":26065.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":26065.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. 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"}]}]},{"description":"HYPERTENSION WITH MCC ","code_information":[{"code":"133","type":"RC"},{"code":"304","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Coronary artery bypass, using arterial graft(s); 3 coronary arterial grafts ","code_information":[{"code":"33535","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":33101.300,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":24148.090,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":29468.850,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":29468.850,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":31285.070,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":33101.300,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Tramadol ","code_information":[{"code":"80373","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.230,"maximum":11.360,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":11.160,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":10.640,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":11.360,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":11.360,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":11.360,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":11.360,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":10.230,"methodology":"fee schedule"}]}]},{"description":"Lithium ion battery charger, replacement only 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"}]}]},{"description":"ACUTE LEUKEMIA WITHOUT CC/MCC ","code_information":[{"code":"836","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1275.000,"maximum":3060.000,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":1275.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3060.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $552131.00, reimbursement will be $6139 per diem instead of the contracted rate."}]}]},{"description":"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EX ","code_information":[{"code":"125","type":"RC"},{"code":"456","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC 3 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"824","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"TESTES PROCEDURES WITH CC/MCC 2 Day Stay","code_information":[{"code":"119","type":"RC"},{"code":"711","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITH CC Pediatric","code_information":[{"code":"133","type":"RC"},{"code":"445","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16032.000,"maximum":21437.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":16032.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":18167.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":21437.000,"methodology":"case rate"}]}]},{"description":"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC 4 Day Stay","code_information":[{"code":"012","type":"MS-DRG"},{"code":"149","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC ","code_information":[{"code":"0D164KL","type":"ICD"},{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2950.000,"maximum":2950.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2950.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"OTHER O.R. PROCEDURES FOR INJURIES WITH MCC 3 Day Stay","code_information":[{"code":"126","type":"RC"},{"code":"907","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; masticator space ","code_information":[{"code":"41018","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":451.360,"maximum":5055.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2550.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3184.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3184.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3373.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3548.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2527.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":451.360,"methodology":"fee schedule"}]}]},{"description":"PULMONARY EDEMA AND RESPIRATORY FAILURE 4 Day Stay","code_information":[{"code":"156","type":"RC"},{"code":"189","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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"}]}]},{"description":"Insertion of 2 transvenous electrodes, permanent pacemaker or implantable defibrillator High Cost Surgery","code_information":[{"code":"33217","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2369.000,"maximum":2369.000,"payers_information":[{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":2369.000,"methodology":"case rate"}]}]},{"description":"Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report ","code_information":[{"code":"344","type":"RC"},{"code":"93315","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":360.100,"maximum":360.100,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":360.100,"methodology":"fee schedule"}]}]},{"description":"VENTRICULAR SHUNT PROCEDURES WITH CC ","code_information":[{"code":"032","type":"MS-DRG"},{"code":"157","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"CHANGE BILE DUCT CATHETER ","code_information":[{"code":"47525","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"DIABETES WITH CC 3 Day Stay","code_information":[{"code":"132","type":"RC"},{"code":"638","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"RADIOTHERAPY ","code_information":[{"code":"152","type":"RC"},{"code":"849","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC 2 Day Stay","code_information":[{"code":"021","type":"MS-DRG"},{"code":"120","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring) ","code_information":[{"code":"480","type":"RC"},{"code":"55873","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10949.000,"maximum":10949.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":10949.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH 2 Day Stay","code_information":[{"code":"124","type":"RC"},{"code":"618","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH 2 Day Stay","code_information":[{"code":"150","type":"RC"},{"code":"542","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Colporrhaphy, suture of injury of vagina (nonobstetrical) ","code_information":[{"code":"481","type":"RC"},{"code":"57200","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1141.200,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4721.410,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":5895.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":5895.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6245.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6570.000,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1141.200,"methodology":"fee schedule"}]}]},{"description":"Arthroplasty, interphalangeal joint; with prosthetic implant, each joint ","code_information":[{"code":"26536","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":678.000,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":3389.670,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":3620.030,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":3620.030,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":3620.030,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":3620.030,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":3258.030,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":678.000,"methodology":"case rate"}]}]},{"description":"Laparotomy, with aspiration and/or injection of hepatic parasitic (eg, amoebic or echinococcal) cyst(s) or abscess(es) ","code_information":[{"code":"47015","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2613.000,"maximum":15757.810,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11495.650,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14028.600,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14028.600,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14893.200,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15757.810,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"}]}]},{"description":"WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE 3 Day Stay","code_information":[{"code":"122","type":"RC"},{"code":"465","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Intrinsic factor ","code_information":[{"code":"307","type":"RC"},{"code":"83528","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.980,"maximum":55.890,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":55.890,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":55.890,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19.820,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":16.980,"methodology":"fee schedule"}]}]},{"description":"HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC ","code_information":[{"code":"132","type":"RC"},{"code":"421","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. 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logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; not otherwise specified, each organism ","code_information":[{"code":"302","type":"RC"},{"code":"87299","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.790,"maximum":45.400,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":45.400,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":45.400,"methodology":"fee 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"}]}]},{"description":"Myelin oligodendrocyte glycoprotein (MOG-IgG1) antibody; cell-based immunofluorescence assay (CBA), each ","code_information":[{"code":"302","type":"RC"},{"code":"86362","type":"CPT"},{"code":"863620","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":10.320,"maximum":12.050,"gross_charge":1043.41,"discounted_cash":1043.41,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":10.320,"methodology":"fee schedule"}]}]},{"description":"Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging ","code_information":[{"code":"340","type":"RC"},{"code":"75559","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":397.050,"maximum":1336.260,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1336.260,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1336.260,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":397.050,"methodology":"fee schedule"}]}]},{"description":"Blood count; red blood cell (RBC), automated ","code_information":[{"code":"301","type":"RC"},{"code":"85041","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2.590,"maximum":10.520,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":10.520,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":10.520,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3.020,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2.590,"methodology":"fee schedule"}]}]},{"description":"Cardiac shunt detection ","code_information":[{"code":"404","type":"RC"},{"code":"78428","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":186.760,"maximum":186.760,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":186.760,"methodology":"fee schedule"}]}]},{"description":"HYPERTENSION WITH MCC 3 Day Stay","code_information":[{"code":"154","type":"RC"},{"code":"304","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"CRANIAL/FACIAL PROCEDURES W CC/MCC Pediatric","code_information":[{"code":"131","type":"MS-DRG"},{"code":"143","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":19168.000,"maximum":25628.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":19168.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":21719.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":25628.000,"methodology":"case rate"}]}]},{"description":"MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES Adult","code_information":[{"code":"483","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":23149.000,"maximum":30954.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":23149.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 20.4% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":26232.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 23.1% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":30954.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 27.3% of billable gross charges instead of the contracted rate."}]}]},{"description":"Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) ","code_information":[{"code":"90474","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":55.120,"maximum":169.560,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":55.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":67.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":67.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":71.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":75.620,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":169.560,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":169.560,"methodology":"fee schedule"}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level ","code_information":[{"code":"367","type":"RC"},{"code":"64483","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2946.000,"maximum":5055.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each ","code_information":[{"code":"28515","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":91.560,"maximum":5841.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":629.150,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":767.670,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":767.670,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":815.260,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":862.840,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":91.560,"methodology":"fee schedule"}]}]},{"description":"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC A ","code_information":[{"code":"062","type":"MS-DRG"},{"code":"116","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"DEPRESSIVE DISORDERS ","code_information":[{"code":"7512","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1738.720,"maximum":2025.920,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":2025.920,"methodology":"fee schedule"},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":1808.970,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1844.090,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1844.090,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1844.090,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1844.090,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1834.510,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1834.510,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1834.510,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1834.510,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1834.510,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":1738.720,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1791.410,"methodology":"fee schedule"}]}]},{"description":"MEDICAL BACK PROBLEMS WITHOUT MCC ","code_information":[{"code":"114","type":"RC"},{"code":"552","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Thromboendarterectomy, including patch graft, if performed; popliteal artery ","code_information":[{"code":"35303","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":16765.190,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":12230.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14925.430,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14925.430,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":15845.310,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16765.190,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WIT 3 Day Stay","code_information":[{"code":"133","type":"RC"},{"code":"563","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Ultrasound bone density measurement and interpretation, peripheral site(s), any method ","code_information":[{"code":"483","type":"RC"},{"code":"76977","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.150,"maximum":7.150,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":7.150,"methodology":"fee schedule"}]}]},{"description":"Open treatment of sternoclavicular dislocation, acute or chronic; ","code_information":[{"code":"23530","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WI 2 Day Stay","code_information":[{"code":"024","type":"MS-DRG"},{"code":"114","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOU 4 Day Stay","code_information":[{"code":"132","type":"RC"},{"code":"641","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"MAJOR BLADDER PROCEDURES WITH MCC ","code_information":[{"code":"157","type":"RC"},{"code":"653","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC 4 Day Stay","code_information":[{"code":"137","type":"RC"},{"code":"372","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Excision of infected graft; abdomen ","code_information":[{"code":"35907","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":25765.610,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":18796.550,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":22938.160,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":22938.160,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":24351.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25765.610,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma ","code_information":[{"code":"369","type":"RC"},{"code":"61510","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":29888.160,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":21804.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":26608.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":26608.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":28248.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":29888.160,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"CHEST PAIN ","code_information":[{"code":"117","type":"RC"},{"code":"313","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s) ","code_information":[{"code":"352","type":"RC"},{"code":"70552","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":288.330,"maximum":288.330,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":288.330,"methodology":"fee schedule"}]}]},{"description":"NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 2 Day Stay","code_information":[{"code":"141","type":"RC"},{"code":"987","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Hemoglobin, quantitative, transcutaneous, per day; carboxyhemoglobin ","code_information":[{"code":"304","type":"RC"},{"code":"88740","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.370,"maximum":26.420,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":26.420,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":26.420,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9.370,"methodology":"fee schedule"}]}]},{"description":"Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm and associated occlusive disease, carotid, subclavian artery, b ","code_information":[{"code":"35001","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15016.350,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10954.740,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":13368.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":13368.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14192.430,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15016.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion ","code_information":[{"code":"480","type":"RC"},{"code":"62365","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6326.000,"maximum":6326.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"VIRAL MENINGITIS WITHOUT CC/MCC ","code_information":[{"code":"076","type":"MS-DRG"},{"code":"159","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Preperitoneal pelvic packing for hemorrhage associated with pelvic trauma, including local exploration ","code_information":[{"code":"49013","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3061.000,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC 4 Day Stay","code_information":[{"code":"148","type":"RC"},{"code":"353","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Insertion of arterial and venous cannula(s) for isolated extracorporeal circulation including regional chemotherapy perfusion to an extremity, with or without hyperthermia, with removal of cannula(s) ","code_information":[{"code":"36823","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3041.000,"maximum":18840.380,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":13744.450,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":16772.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":16772.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":17806.640,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":18840.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5851.000,"methodology":"case rate"}]}]},{"description":"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC ","code_information":[{"code":"127","type":"RC"},{"code":"436","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); goniosynechiae ","code_information":[{"code":"362","type":"RC"},{"code":"65865","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2946.000,"maximum":5055.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HYPERTENSION WITH MCC 3 Day Stay","code_information":[{"code":"118","type":"RC"},{"code":"304","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Antibody; Candida ","code_information":[{"code":"303","type":"RC"},{"code":"86628","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.290,"maximum":41.790,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":41.790,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":41.790,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.010,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":10.290,"methodology":"fee schedule"}]}]},{"description":"Application of long leg cast brace ","code_information":[{"code":"29358","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":81.120,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":84.400,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":90.130,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":90.130,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":90.130,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":90.130,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":81.120,"methodology":"fee schedule"}]}]},{"description":"OTHER CEREBROVASCULAR DISORDERS WITH MCC 3 Day Stay","code_information":[{"code":"070","type":"MS-DRG"},{"code":"141","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Direct or patch closure, sinus venosus, with or without anomalous pulmonary venous drainage ","code_information":[{"code":"33645","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":23265.990,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":16973.030,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":20712.840,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":20712.840,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":21989.420,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":23265.990,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"HPercutaneous implantation of neurostimulator electrode array; neuromuscular ","code_information":[{"code":"490","type":"RC"},{"code":"64565","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":65666.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9124.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":65666.000,"methodology":"case rate"}]}]},{"description":"Bile acids; total ","code_information":[{"code":"314","type":"RC"},{"code":"82239","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.670,"maximum":59.610,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":59.610,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":59.610,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":14.670,"methodology":"fee schedule"}]}]},{"description":"SKIN DEBRIDEMENT WITH CC 4 Day Stay","code_information":[{"code":"101","type":"RC"},{"code":"571","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"CHOLECYSTECTOMY WITH C.D.E. WITH MCC 4 Day Stay","code_information":[{"code":"119","type":"RC"},{"code":"411","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Unlisted laparoscopy procedure, bladder ","code_information":[{"code":"480","type":"RC"},{"code":"51999","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6326.000,"maximum":6326.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Unlisted laparoscopy procedure, uterus High Cost Surgery","code_information":[{"code":"361","type":"RC"},{"code":"58578","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2369.000,"maximum":2369.000,"payers_information":[{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":2369.000,"methodology":"case rate"}]}]},{"description":"WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE ","code_information":[{"code":"160","type":"RC"},{"code":"464","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Application of long arm splint (shoulder to hand) ","code_information":[{"code":"29105","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"APPENDIX PROCEDURES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"158","type":"RC"},{"code":"399","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC 3 Day Stay","code_information":[{"code":"124","type":"RC"},{"code":"519","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Valvuloplasty, tricuspid valve; without ring insertion ","code_information":[{"code":"33463","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hyaluronan or derivative, euflexxa, for intra-articular injection, per dose ","code_information":[{"code":"344","type":"RC"},{"code":"J7323","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":174.010,"maximum":174.010,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":174.010,"methodology":"fee schedule"}]}]},{"description":"Osteotomy, periacetabular, with internal fixation ","code_information":[{"code":"499","type":"RC"},{"code":"S2115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":13988.660,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10205.020,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12453.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12453.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13221.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13988.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC ","code_information":[{"code":"129","type":"RC"},{"code":"267","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Major reconstruction, chest wall (posttraumatic) ","code_information":[{"code":"32820","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":17898.350,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":13057.220,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":15934.230,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":15934.230,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":16916.290,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17898.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"036","type":"MS-DRG"},{"code":"147","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WIT 3 Day Stay","code_information":[{"code":"126","type":"RC"},{"code":"563","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC 4 Day Stay","code_information":[{"code":"112","type":"RC"},{"code":"957","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"SKIN ULCERS WITH MCC 4 Day Stay","code_information":[{"code":"132","type":"RC"},{"code":"592","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence score ","code_information":[{"code":"305","type":"RC"},{"code":"81519","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3318.390,"maximum":10921.860,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":10921.860,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":10921.860,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3873.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":3318.390,"methodology":"fee schedule"}]}]},{"description":"INBORN AND OTHER DISORDERS OF METABOLISM 4 Day Stay","code_information":[{"code":"115","type":"RC"},{"code":"642","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"MEDICAL BACK PROBLEMS WITH MCC 4 Day Stay","code_information":[{"code":"167","type":"RC"},{"code":"551","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Ablation, malignant breast tumor(s), percutaneous, cryotherapy, including imaging guidance when performed, unilateral ","code_information":[{"code":"0581T","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZA 3 Day Stay","code_information":[{"code":"156","type":"RC"},{"code":"218","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Procalcitonin (PCT) ","code_information":[{"code":"304","type":"RC"},{"code":"84145","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":23.320,"maximum":93.290,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":93.290,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":93.290,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":27.220,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":23.320,"methodology":"fee schedule"}]}]},{"description":"VEIN LIGATION AND STRIPPING 2 Day Stay","code_information":[{"code":"137","type":"RC"},{"code":"263","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Percutaneous transluminal coronary angioplasty; each additional branch of a major coronary artery (List separately in addition to code for primary procedure) ","code_information":[{"code":"361","type":"RC"},{"code":"92921","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":11460.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited ","code_information":[{"code":"351","type":"RC"},{"code":"76642","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":87.250,"maximum":87.250,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":87.250,"methodology":"fee schedule"}]}]},{"description":"Insertion of tunneled intraperitoneal catheter for dialysis, open ","code_information":[{"code":"481","type":"RC"},{"code":"49421","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1235.650,"maximum":15410.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5876.650,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7338.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7338.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7773.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8177.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1235.650,"methodology":"fee schedule"}]}]},{"description":"Lead ","code_information":[{"code":"301","type":"RC"},{"code":"83655","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.370,"maximum":42.160,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":42.160,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":42.160,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.110,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":10.370,"methodology":"fee schedule"}]}]},{"description":"ABORTION WITHOUT D&C 3 Day Stay","code_information":[{"code":"122","type":"RC"},{"code":"779","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"SPLENIC PROCEDURES WITH MCC 4 Day Stay","code_information":[{"code":"125","type":"RC"},{"code":"799","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"VENTRICULAR SHUNT PROCEDURES WITH CC 3 Day Stay","code_information":[{"code":"032","type":"MS-DRG"},{"code":"145","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area ","code_information":[{"code":"27335","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15732.530,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11305.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14954.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15732.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2573.700,"methodology":"fee schedule"}]}]},{"description":"Drug metabolism or processing (mult conditions), whole blood or buccal specimen, DNA analysis, 16 gene report, with variant analysis and reported phenotypes ","code_information":[{"code":"0347U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1336.090,"maximum":1336.090,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1336.090,"methodology":"fee schedule"}]}]},{"description":"FOOT PROCEDURES WITH MCC 3 Day Stay","code_information":[{"code":"145","type":"RC"},{"code":"503","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Bypass graft, with other than vein; axillary-popliteal or -tibial ","code_information":[{"code":"35623","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"131","type":"RC"},{"code":"331","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC 4 Day Stay","code_information":[{"code":"098","type":"MS-DRG"},{"code":"115","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Suture of nerve; requiring shortening of bone of extremity (List separately in addition to code for nerve suture) ","code_information":[{"code":"480","type":"RC"},{"code":"64876","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of laceration 2.5 cm or less; floor of mouth and/or anterior two-thirds of tongue ","code_information":[{"code":"41250","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"159","type":"RC"},{"code":"422","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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"}]}]},{"description":"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC 4 Day Stay","code_information":[{"code":"112","type":"RC"},{"code":"629","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study ","code_information":[{"code":"340","type":"RC"},{"code":"93976","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":111.150,"maximum":111.150,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":111.150,"methodology":"fee schedule"}]}]},{"description":"COMPLICATED PEPTIC ULCER WITHOUT CC/MCC ","code_information":[{"code":"144","type":"RC"},{"code":"382","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Arthrodesis, carpometacarpal joint, digit, other than thumb, each; ","code_information":[{"code":"26843","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3488.950,"maximum":15732.530,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11305.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14954.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15732.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":3488.950,"methodology":"fee schedule"}]}]},{"description":"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC ","code_information":[{"code":"169","type":"RC"},{"code":"271","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC ","code_information":[{"code":"164","type":"RC"},{"code":"256","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material ","code_information":[{"code":"73721","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":215.060,"maximum":215.060,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":215.060,"methodology":"fee schedule"}]}]},{"description":"Amputation, ankle, through malleoli of tibia and fibula (eg, Syme, Pirogoff type procedures), with plastic closure and resection of nerves ","code_information":[{"code":"27888","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":15581.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":6484.430,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7913.200,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7913.200,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":8400.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8888.620,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC ","code_information":[{"code":"119","type":"RC"},{"code":"742","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Radiologic examination, internal auditory meati, complete ","code_information":[{"code":"615","type":"RC"},{"code":"70134","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":63.050,"maximum":63.050,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":63.050,"methodology":"fee schedule"}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC ","code_information":[{"code":"157","type":"RC"},{"code":"658","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Instillation, bupivacaine and meloxicam, 1 mg/0.03 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J0668","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1.370,"maximum":1.370,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1.370,"methodology":"fee schedule"}]}]},{"description":"MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC ","code_information":[{"code":"115","type":"RC"},{"code":"448","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC ","code_information":[{"code":"116","type":"RC"},{"code":"896","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture of oocyte(s)/embryos ","code_information":[{"code":"310","type":"RC"},{"code":"89251","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2639.630,"maximum":2639.630,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":2639.630,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":2639.630,"methodology":"fee schedule"}]}]},{"description":"CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION ","code_information":[{"code":"111","type":"RC"},{"code":"317","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"REVISION OF TENNIS ELBOW ","code_information":[{"code":"24356","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC 3 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"657","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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"}]}]},{"description":"Injection, ceftolozane 50 mg and tazobactam 25 mg ","drug_information":{"unit":1.500000000000000e+000,"type":"GM"},"code_information":[{"code":"350807","type":"CDM"},{"code":"J0695","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8.040,"maximum":73.600,"gross_charge":429.02,"discounted_cash":429.02,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13.220,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":17.800,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":20.270,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":23.920,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":73.600,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":73.600,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":8.040,"methodology":"fee schedule"}]}]},{"description":"OTHER DISORDERS OF THE EYE WITHOUT MCC 4 Day Stay","code_information":[{"code":"125","type":"MS-DRG"},{"code":"134","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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"}]}]},{"description":"LUNG TRANSPLANT 2 Day Stay","code_information":[{"code":"007","type":"MS-DRG"},{"code":"132","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"MEDICAL BACK PROBLEMS WITHOUT MCC ","code_information":[{"code":"146","type":"RC"},{"code":"552","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"Tenotomy, shoulder area; multiple tendons through same incision ","code_information":[{"code":"23406","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4988.000,"maximum":4988.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; with tendon graft(s) (includes obtaining graft), each tendon ","code_information":[{"code":"25312","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12635.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1373.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure 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"}]}]},{"description":"MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND CO ","code_information":[{"code":"114","type":"RC"},{"code":"808","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WI ","code_information":[{"code":"023","type":"MS-DRG"},{"code":"114","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"Radiologic examination, sacroiliac joints; 3 or more views ","code_information":[{"code":"614","type":"RC"},{"code":"72202","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":40.220,"maximum":40.220,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":40.220,"methodology":"fee schedule"}]}]},{"description":"Injection procedure; lymphangiography ","code_information":[{"code":"369","type":"RC"},{"code":"38790","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1672.000,"maximum":5841.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"Venipuncture, cutdown; age 1 or over ","code_information":[{"code":"36425","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":687.190,"maximum":5055.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":687.190,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":858.070,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":858.070,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":908.970,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":956.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"CHOLECYSTECTOMY WITH C.D.E. 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"}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC ","code_information":[{"code":"137","type":"RC"},{"code":"757","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Transection or avulsion of; infraorbital nerve ","code_information":[{"code":"64734","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":708.150,"maximum":5487.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3249.570,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":4057.670,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":4057.670,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":4298.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4521.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":708.150,"methodology":"fee schedule"}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCE 3 Day Stay","code_information":[{"code":"157","type":"RC"},{"code":"829","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Capsular contracture release (eg, Sever type procedure) ","code_information":[{"code":"23020","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15410.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1373.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC 3 Day Stay","code_information":[{"code":"148","type":"RC"},{"code":"271","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Magnetic resonance (eg, vibration) elastography ","code_information":[{"code":"76391","type":"CPT"},{"code":"921","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":215.730,"maximum":215.730,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":215.730,"methodology":"fee schedule"}]}]},{"description":"SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC 4 Day Stay","code_information":[{"code":"116","type":"RC"},{"code":"555","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Testicular imaging with vascular flow ","code_information":[{"code":"78761","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":212.320,"maximum":212.320,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":212.320,"methodology":"fee schedule"}]}]},{"description":"URETHRAL PROCEDURES WITH CC/MCC ","code_information":[{"code":"157","type":"RC"},{"code":"671","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC ","code_information":[{"code":"101","type":"RC"},{"code":"918","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Cardiokymography ","code_information":[{"code":"352","type":"RC"},{"code":"Q0035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":20.040,"maximum":20.040,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":20.040,"methodology":"fee schedule"}]}]},{"description":"OTHER DISORDERS OF NERVOUS SYSTEM WITH CC 4 Day Stay","code_information":[{"code":"092","type":"MS-DRG"},{"code":"141","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC ","code_information":[{"code":"117","type":"RC"},{"code":"745","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC ","code_information":[{"code":"068","type":"MS-DRG"},{"code":"131","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contras ","code_information":[{"code":"369","type":"RC"},{"code":"36901","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":478.870,"maximum":5841.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":563.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3412.090,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":4163.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":4163.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":4421.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4679.430,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2527.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2650.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":478.870,"methodology":"fee schedule"}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"144","type":"RC"},{"code":"446","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":7118.040,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":7601.790,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":7601.790,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":7601.790,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":7601.790,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":6841.610,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":595.000,"methodology":"case rate"}]}]},{"description":"Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure) ","code_information":[{"code":"20937","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4988.000,"maximum":15410.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"}]}]},{"description":"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC ","code_information":[{"code":"100","type":"RC"},{"code":"559","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Excision of thyroglossal duct cyst or sinus; recurrent ","code_information":[{"code":"490","type":"RC"},{"code":"60281","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15581.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9135.710,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11407.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11407.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12084.270,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12712.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9124.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2026.810,"methodology":"fee schedule"}]}]},{"description":"Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) ","code_information":[{"code":"43260","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3041.000,"maximum":3041.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; subcortical structure(s) other than globus pallidus or thalamus ","code_information":[{"code":"360","type":"RC"},{"code":"61735","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":21824.990,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":15921.790,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":19429.980,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":19429.980,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":20627.480,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":21824.990,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Culture, typing; identification by nucleic acid sequencing method, each isolate (eg, sequencing of the 16S rRNA gene) ","code_information":[{"code":"311","type":"RC"},{"code":"87153","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":98.840,"maximum":401.620,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":401.620,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":401.620,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":98.840,"methodology":"fee schedule"}]}]},{"description":"PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC ","code_information":[{"code":"142","type":"RC"},{"code":"243","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC ","code_information":[{"code":"148","type":"RC"},{"code":"555","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Tacrolimus ","code_information":[{"code":"306","type":"RC"},{"code":"80197","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.760,"maximum":47.830,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":47.830,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":47.830,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.730,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":11.760,"methodology":"fee schedule"}]}]},{"description":"Open treatment of nasal septal fracture, with or without stabilization ","code_information":[{"code":"21336","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3041.000,"maximum":3041.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Dexametha opth insert 0.1 ","code_information":[{"code":"9308","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":96.680,"maximum":239.740,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":99.500,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":98.660,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":103.590,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":98.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":98.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":98.660,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":98.660,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":98.660,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":98.660,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":98.660,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":98.660,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":195.340,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":197.310,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":98.660,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":98.660,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":98.660,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":98.660,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":98.660,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":98.660,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":107.540,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":239.740,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":207.180,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":103.590,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":103.590,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":104.580,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":104.580,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":104.580,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":104.580,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":104.580,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":103.590,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":152.920,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":103.590,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":103.590,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":103.590,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":98.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":100.630,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":118.390,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":96.680,"methodology":"fee schedule"}]}]},{"description":"Transection or repositioning of aberrant renal vessels (separate procedure) ","code_information":[{"code":"499","type":"RC"},{"code":"50100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":14186.250,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10349.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12629.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12629.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13407.870,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14186.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Obstetric panel (includes HIV testing) This panel must include the following: Blood count, complete (CBC), and automated differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC ","code_information":[{"code":"304","type":"RC"},{"code":"80081","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":64.140,"maximum":260.620,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":260.620,"methodology":"fee 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"}]}]},{"description":"Optical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center, unilateral or bilateral; initial device provision, set-up and pa ","code_information":[{"code":"0604T","type":"CPT"},{"code":"321","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":267.170,"maximum":267.170,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":267.170,"methodology":"fee schedule"}]}]},{"description":"Treatment planning for magnetic field induction ablation of malignant prostate tissue, using data from previously performed magnetic resonance imaging (MRI) examination ","code_information":[{"code":"0738T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"FOOT PROCEDURES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"130","type":"RC"},{"code":"505","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC ","code_information":[{"code":"565","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1275.000,"maximum":3060.000,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":1275.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3060.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $552131.00, reimbursement will be $6139 per diem instead of the contracted rate."}]}]},{"description":"Epidermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedur ","code_information":[{"code":"15111","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":5841.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC ","code_information":[{"code":"119","type":"RC"},{"code":"155","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy with partial resection of uterus ","code_information":[{"code":"59136","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":12018.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8665.160,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":10574.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":10574.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":11226.160,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11877.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"144","type":"RC"},{"code":"547","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC 4 Day Stay","code_information":[{"code":"112","type":"RC"},{"code":"474","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"SKIN GRAFTS FOR INJURIES WITH CC/MCC ","code_information":[{"code":"121","type":"RC"},{"code":"904","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Venography, renal, unilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"75831","type":"CPT"},{"code":"921","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":123.040,"maximum":123.040,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":123.040,"methodology":"fee schedule"}]}]},{"description":"Therapeutic radiology treatment planning; complex ","code_information":[{"code":"409","type":"RC"},{"code":"77263","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":514.260,"maximum":514.260,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":514.260,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":514.260,"methodology":"fee schedule"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"164","type":"RC"},{"code":"833","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC 3 Day Stay","code_information":[{"code":"002","type":"MS-DRG"},{"code":"164","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC ","code_information":[{"code":"140","type":"RC"},{"code":"903","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Removal of total disc arthroplasty, (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure) ","code_information":[{"code":"0164T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1672.000,"maximum":13988.660,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10205.020,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12453.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12453.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13221.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13988.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC ","code_information":[{"code":"138","type":"RC"},{"code":"435","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"GASTROINTESTINAL HEMORRHAGE WITH CC ","code_information":[{"code":"143","type":"RC"},{"code":"378","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC 4 Day Stay","code_information":[{"code":"123","type":"RC"},{"code":"867","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed; requirin ","code_information":[{"code":"95991","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":174.590,"maximum":1040.110,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":174.590,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":213.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":213.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":226.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":239.500,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1040.110,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1040.110,"methodology":"fee schedule"}]}]},{"description":"PNEUMOTHORAX WITH MCC ","code_information":[{"code":"151","type":"RC"},{"code":"199","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without anesthesia ","code_information":[{"code":"26700","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":84.470,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":87.880,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":93.850,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":93.850,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":93.850,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":93.850,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":84.470,"methodology":"fee schedule"}]}]},{"description":"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC 3 Day Stay","code_information":[{"code":"132","type":"RC"},{"code":"559","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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"}]}]},{"description":"Application of a modality to 1 or more areas; paraffin bath ","code_information":[{"code":"97018","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.670,"maximum":116.130,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":5.840,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":5.790,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":6.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":30.640,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":37.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":37.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":39.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":5.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":5.790,"methodology":"fee 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"}]}]},{"description":"Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or detected ","code_information":[{"code":"0017U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":89.830,"maximum":1542.510,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":92.440,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":91.660,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":96.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":209.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":255.730,"methodology":"fee 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3684.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3898.690,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"ENDOCRINE DISORDERS WITHOUT CC/MCC 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"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":7862.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":4598.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC 3 Day Stay","code_information":[{"code":"135","type":"RC"},{"code":"273","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":4720.540,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4994.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":52973.010,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":56115.470,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":59033.480,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":25939.000,"methodology":"case rate"}]}]},{"description":"COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC 4 Day 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"}]}]},{"description":"Computed tomography, abdomen and pelvis; without contrast material ","code_information":[{"code":"619","type":"RC"},{"code":"74176","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":193.590,"maximum":193.590,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":193.590,"methodology":"fee schedule"}]}]},{"description":"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISOR 2 Day Stay","code_information":[{"code":"111","type":"RC"},{"code":"623","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (eg, maze procedure), with cardiopulmonary bypass (List separately in addition to ","code_information":[{"code":"33259","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12018.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8304.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":10134.260,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":10134.260,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":10758.850,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11383.450,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC ","code_information":[{"code":"133","type":"RC"},{"code":"660","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC 2 Day Stay","code_information":[{"code":"149","type":"RC"},{"code":"722","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Thyroid imaging (including vascular flow, when performed); ","code_information":[{"code":"78013","type":"CPT"},{"code":"929","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":182.000,"maximum":182.000,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":182.000,"methodology":"fee schedule"}]}]},{"description":"ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC ","code_information":[{"code":"127","type":"RC"},{"code":"288","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"VENTRICULAR SHUNT PROCEDURES WITH CC 2 Day Stay","code_information":[{"code":"032","type":"MS-DRG"},{"code":"117","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Cholecystectomy; with cholangiography ","code_information":[{"code":"361","type":"RC"},{"code":"47605","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":15202.820,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11090.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":13534.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":13534.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14368.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15202.820,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC Pediatric","code_information":[{"code":"122","type":"MS-DRG"},{"code":"153","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":10610.000,"maximum":14187.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":10610.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":12023.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":14187.000,"methodology":"case rate"}]}]},{"description":"DIABETES WITH MCC 3 Day Stay","code_information":[{"code":"151","type":"RC"},{"code":"637","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"PULMONARY EMBOLISM WITHOUT MCC ","code_information":[{"code":"100","type":"RC"},{"code":"176","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Myelography, cervical, radiological supervision and interpretation ","code_information":[{"code":"342","type":"RC"},{"code":"72240","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":117.590,"maximum":295.310,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":295.310,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":295.310,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":117.590,"methodology":"fee schedule"}]}]},{"description":"Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) ","code_information":[{"code":"21206","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2096.960,"maximum":12756.890,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":2467.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9167.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11447.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11447.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12126.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12756.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7367.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8349.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2096.960,"methodology":"fee schedule"}]}]},{"description":"FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC ","code_information":[{"code":"148","type":"RC"},{"code":"928","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC 2 Day Stay","code_information":[{"code":"152","type":"RC"},{"code":"451","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE ","code_information":[{"code":"150","type":"RC"},{"code":"175","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, includes internal fixation, when performed, each ","code_information":[{"code":"26735","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12635.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1373.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"066","type":"MS-DRG"},{"code":"132","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC 2 Day Stay","code_information":[{"code":"160","type":"RC"},{"code":"519","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Autologous muscle cell therapy, administration of muscle progenitor cells into the urethral sphincter, including cystoscopy and post-void residual ultrasound, when performed ","code_information":[{"code":"1000T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":2333.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, ankle; complete, minimum of 3 views ","code_information":[{"code":"359","type":"RC"},{"code":"73610","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":37.830,"maximum":37.830,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":37.830,"methodology":"fee schedule"}]}]},{"description":"AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC 4 Day Stay","code_information":[{"code":"112","type":"RC"},{"code":"239","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Level 1 Imaging without C ","code_information":[{"code":"T5521","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":70.770,"maximum":70.770,"payers_information":[{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":70.770,"methodology":"fee schedule"}]}]},{"description":"Tenotomy, open, tendon flexor; foot, single or multiple tendon(s) (separate procedure) ","code_information":[{"code":"28230","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":237.960,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1672.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":2041.080,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":2041.080,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":2167.590,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2294.100,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":237.960,"methodology":"fee schedule"}]}]},{"description":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETER ","code_information":[{"code":"138","type":"RC"},{"code":"220","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC ","code_information":[{"code":"086","type":"MS-DRG"},{"code":"101","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC 2 Day Stay","code_information":[{"code":"158","type":"RC"},{"code":"423","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC ","code_information":[{"code":"091","type":"MS-DRG"},{"code":"113","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"SPLENIC PROCEDURES WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"154","type":"RC"},{"code":"801","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Rem exostosis any site ","code_information":[{"code":"367","type":"RC"},{"code":"D7471","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Internal anastomosis of pancreatic cyst to gastrointestinal tract; direct ","code_information":[{"code":"48520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3061.000,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Thyroid carcinoma metastases imaging; limited area (eg, neck and chest only) ","code_information":[{"code":"359","type":"RC"},{"code":"78015","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":227.320,"maximum":227.320,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":227.320,"methodology":"fee schedule"}]}]},{"description":"OTHER DISORDERS OF THE EYE WITHOUT MCC ","code_information":[{"code":"125","type":"MS-DRG"},{"code":"164","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"Radiologic examination, abdomen; 1 view ","code_information":[{"code":"404","type":"RC"},{"code":"74018","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30.680,"maximum":30.680,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":30.680,"methodology":"fee schedule"}]}]},{"description":"PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH 2 Day Stay","code_information":[{"code":"169","type":"RC"},{"code":"542","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC 2 Day Stay","code_information":[{"code":"130","type":"RC"},{"code":"560","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Repair of central venous access device, with subcutaneous port or pump, central or peripheral insertion site ","code_information":[{"code":"36576","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":422.000,"maximum":11077.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3589.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2768.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2768.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":2630.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":3257.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1904.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":459.660,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":490.900,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":490.900,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":490.900,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":490.900,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":11077.000,"methodology":"case rate"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":441.810,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":422.000,"methodology":"case rate"}]}]},{"description":"EXTERNAL CIRCULATION ASSIST ","code_information":[{"code":"33961","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Colposcopy of the entire vagina, with cervix if present; ","code_information":[{"code":"369","type":"RC"},{"code":"57420","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":62.090,"maximum":5841.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":73.040,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":375.800,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":458.540,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":458.540,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":486.960,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":515.390,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":62.090,"methodology":"fee schedule"}]}]},{"description":"OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"120","type":"RC"},{"code":"168","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC ","code_information":[{"code":"101","type":"RC"},{"code":"487","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Selective enzymatic debridement, partial-thickness and/or full-thickness burn eschar, requiring anesthesia (ie, general anesthesia, moderate sedation), including patient monitoring, scalp, neck, hands ","code_information":[{"code":"0976T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2115.000,"maximum":2115.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"138","type":"RC"},{"code":"759","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC 2 Day Stay","code_information":[{"code":"154","type":"RC"},{"code":"957","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"SEPTIC ARTHRITIS WITH CC 3 Day Stay","code_information":[{"code":"146","type":"RC"},{"code":"549","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC 2 Day Stay","code_information":[{"code":"085","type":"MS-DRG"},{"code":"136","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC ","code_information":[{"code":"116","type":"RC"},{"code":"329","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"NERVOUS SYSTEM NEOPLASMS WITH MCC 2 Day Stay","code_information":[{"code":"054","type":"MS-DRG"},{"code":"143","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"SKIN GRAFTS FOR INJURIES WITH CC/MCC 3 Day Stay","code_information":[{"code":"125","type":"RC"},{"code":"904","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"COMPLICATIONS OF TREATMENT WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"921","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Coronary artery bypass, vein only; 3 coronary venous grafts ","code_information":[{"code":"33512","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":32630.280,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":23804.470,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":29049.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":29049.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":30839.900,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":32630.280,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC 2 Day Stay","code_information":[{"code":"156","type":"RC"},{"code":"229","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Punch biopsy of skin (including simple closure, when performed); each separate/additional lesion (List separately in addition to code for primary procedure) ","code_information":[{"code":"11105","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":5841.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, amplified probe technique ","code_information":[{"code":"306","type":"RC"},{"code":"87561","type":"CPT"},{"code":"875610","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":30.070,"maximum":122.190,"gross_charge":470.83,"discounted_cash":470.83,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":122.190,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":122.190,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":30.070,"methodology":"fee schedule"}]}]},{"description":"INBORN AND OTHER DISORDERS OF METABOLISM ","code_information":[{"code":"116","type":"RC"},{"code":"642","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC Adult","code_information":[{"code":"414","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":52456.000,"maximum":70140.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":52456.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 20.4% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":59441.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 23.1% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":70140.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 27.3% of billable gross charges instead of the contracted rate."}]}]},{"description":"ACUTE LEUKEMIA WITH CC 4 Day Stay","code_information":[{"code":"112","type":"RC"},{"code":"835","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"INTERSTITIAL LUNG DISEASE WITH CC 4 Day Stay","code_information":[{"code":"130","type":"RC"},{"code":"197","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC 2 Day Stay","code_information":[{"code":"001","type":"MS-DRG"},{"code":"169","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Incision and drainage, shoulder area; infected bursa ","code_information":[{"code":"23031","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":874.740,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4382.700,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":5472.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":5472.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":5797.220,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6098.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":874.740,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy with irrigation and evacuation of multiple obstructing clots ","code_information":[{"code":"360","type":"RC"},{"code":"52001","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":7938.760,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1442.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5705.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7123.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7123.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7546.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7938.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health 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"}]}]},{"description":"1-stage perineal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap ","code_information":[{"code":"54336","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15410.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5705.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7123.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7123.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7546.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7938.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"}]}]},{"description":"Susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration ºMIC» or breakpoint), each multi-antimicrobial, per plate ","code_information":[{"code":"311","type":"RC"},{"code":"87186","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.420,"maximum":30.090,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":30.090,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":30.090,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":7.420,"methodology":"fee schedule"}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH CC 4 Day Stay","code_information":[{"code":"169","type":"RC"},{"code":"300","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Laparoscopy, surgical; with fulguration of oviducts (with or without transection) ","code_information":[{"code":"499","type":"RC"},{"code":"58670","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2026.810,"maximum":15581.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9135.710,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11407.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11407.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12084.270,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12712.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9124.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2026.810,"methodology":"fee schedule"}]}]},{"description":"RENAL FAILURE WITHOUT CC/MCC ","code_information":[{"code":"110","type":"RC"},{"code":"684","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"ORBITAL PROCEDURES WITHOUT CC/MCC Adult","code_information":[{"code":"114","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14684.000,"maximum":19634.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":14684.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 20.4% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":16639.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 23.1% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19634.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 27.3% of billable gross charges instead of the contracted rate."}]}]},{"description":"MEDICAL BACK PROBLEMS WITH MCC 2 Day Stay","code_information":[{"code":"150","type":"RC"},{"code":"551","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Dilation of anal sphincter (separate procedure) under anesthesia other than local ","code_information":[{"code":"45905","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":460.610,"maximum":5055.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1897.980,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":2369.960,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":2369.960,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":2510.550,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2641.100,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":460.610,"methodology":"fee schedule"}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"157","type":"RC"},{"code":"195","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Insertion of tandem cuff (dual cuff) ","code_information":[{"code":"367","type":"RC"},{"code":"53444","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":5487.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Intracapsular cataract extraction with insertion of intraocular lens prosthesis (1 stage procedure) ","code_information":[{"code":"360","type":"RC"},{"code":"66983","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":912.020,"maximum":12635.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1072.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3821.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":4771.590,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":4771.590,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":5054.650,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5317.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7684.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8707.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":10274.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":912.020,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography, abdomen, with or without contrast material(s) ","code_information":[{"code":"616","type":"RC"},{"code":"74185","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":672.820,"maximum":3090.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3090.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2385.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2385.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":2265.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":2807.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1641.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":672.820,"methodology":"fee schedule"}]}]},{"description":"AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC ","code_information":[{"code":"101","type":"RC"},{"code":"475","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC Adult","code_information":[{"code":"086","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12435.000,"maximum":16628.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":12435.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 20.4% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":14091.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 23.1% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16628.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 27.3% of billable gross charges instead of the contracted rate."}]}]},{"description":"Bilirubin; feces, qualitative ","code_information":[{"code":"319","type":"RC"},{"code":"82252","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3.910,"maximum":15.880,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":15.880,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":15.880,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":3.910,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC 2 Day Stay","code_information":[{"code":"147","type":"RC"},{"code":"754","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY 3 Day Stay","code_information":[{"code":"152","type":"RC"},{"code":"450","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"PROSTATECTOMY WITH MCC 4 Day Stay","code_information":[{"code":"116","type":"RC"},{"code":"665","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of tibia only ","code_information":[{"code":"27827","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC Pediatric","code_information":[{"code":"143","type":"RC"},{"code":"354","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14106.000,"maximum":18861.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":14106.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":15984.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":18861.000,"methodology":"case rate"}]}]},{"description":"POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. 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"}]}]},{"description":"Laparoscopy, surgical; with insertion of tunneled intraperitoneal catheter ","code_information":[{"code":"49324","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2026.810,"maximum":13370.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9135.710,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11407.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11407.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12084.270,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12712.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":9999.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":11331.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":13370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2026.810,"methodology":"fee schedule"}]}]},{"description":"Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I ","code_information":[{"code":"21154","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantificat ","code_information":[{"code":"78452","type":"CPT"},{"code":"78465","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":433.670,"maximum":9508.080,"gross_charge":11091.70,"discounted_cash":11091.70,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","median_amount":1815.680,"10th_percentile":1815.680,"90th_percentile":1815.680,"count":"1 through 10","methodology":"percent of total billed charges","additional_payer_notes":" Between 1-10 instances of this service in the last 15 months prior to posting and may not be statistically significant. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":503.040,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":925.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1207.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1207.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1367.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1527.060,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7108.530,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8054.830,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9508.080,"methodology":"fee schedule"},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":451.190,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":481.860,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":481.860,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":481.860,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":481.860,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":433.670,"methodology":"fee schedule"}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"112","type":"RC"},{"code":"301","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only ","code_information":[{"code":"483","type":"RC"},{"code":"93316","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.930,"maximum":26.930,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":26.930,"methodology":"fee schedule"}]}]},{"description":"Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; additional 1 sq cm to 75 sq cm (List separately in addition to code for ","code_information":[{"code":"15156","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1672.000,"maximum":5841.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"157","type":"RC"},{"code":"352","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Drug metabolism (warfarin drug response), targeted sequence analysis (ie, CYP2C9, CYP4F2, VKORC1, rs12777823) ","code_information":[{"code":"0030U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":134.130,"maximum":134.130,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":134.130,"methodology":"fee schedule"}]}]},{"description":"COMPLICATED PEPTIC ULCER WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"143","type":"RC"},{"code":"382","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC 2 Day Stay","code_information":[{"code":"147","type":"RC"},{"code":"817","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"MINOR BLADDER PROCEDURES WITH MCC 4 Day Stay","code_information":[{"code":"123","type":"RC"},{"code":"662","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, w ","code_information":[{"code":"314","type":"RC"},{"code":"81003","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1.930,"maximum":7.810,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":7.810,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":7.810,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1.930,"methodology":"fee schedule"}]}]},{"description":"Suture of iris, ciliary body (separate procedure) with retrieval of suture through small incision (eg, McCannel suture) ","code_information":[{"code":"362","type":"RC"},{"code":"66682","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":5487.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC Pediatric","code_information":[{"code":"203","type":"RC"},{"code":"627","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12670.000,"maximum":16942.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":12670.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":14358.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16942.000,"methodology":"case rate"}]}]},{"description":"Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation ","code_information":[{"code":"320","type":"RC"},{"code":"77054","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":70.540,"maximum":228.590,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":228.590,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":228.590,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":70.540,"methodology":"fee schedule"}]}]},{"description":"CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC 2 Day Stay","code_information":[{"code":"157","type":"RC"},{"code":"236","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; axillary nerve, including imaging guidance, when performed ","code_information":[{"code":"480","type":"RC"},{"code":"64417","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2251.000,"maximum":2251.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2251.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"124","type":"RC"},{"code":"355","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"URETHRAL STRICTURE 2 Day Stay","code_information":[{"code":"140","type":"RC"},{"code":"697","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC 3 Day Stay","code_information":[{"code":"112","type":"RC"},{"code":"250","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; superficial, includes autograft, when performed ","code_information":[{"code":"27065","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15732.530,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":3027.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11305.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14954.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15732.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7367.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8349.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2573.700,"methodology":"fee schedule"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MC 3 Day Stay","code_information":[{"code":"125","type":"RC"},{"code":"517","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC 4 Day Stay","code_information":[{"code":"138","type":"RC"},{"code":"715","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"URETHRAL PROCEDURES WITH CC/MCC 4 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"671","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); ","code_information":[{"code":"59612","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4721.410,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4721.410,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":5895.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":5895.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6245.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6570.000,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"}]}]},{"description":"Pelvic examination under anesthesia (other than local) ","code_information":[{"code":"481","type":"RC"},{"code":"57410","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1141.200,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4721.410,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":5895.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":5895.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6245.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6570.000,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1141.200,"methodology":"fee schedule"}]}]},{"description":"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC 3 Day Stay","code_information":[{"code":"152","type":"RC"},{"code":"559","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"FRACTURES OF HIP AND PELVIS WITH MCC 2 Day Stay","code_information":[{"code":"129","type":"RC"},{"code":"535","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"MOUTH PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"138","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.000,"maximum":18127.280,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":11542.980,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_dollar":7444.080,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_dollar":9305.100,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":11695.020,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":12279.770,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Averde Health","plan_name":"COMM","standard_charge_percentage":33.00,"standard_charge_algorithm":"Reimbursement will be 33% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":13534.410,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":15029.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":15029.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":15159.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":11695.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":11695.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":11695.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15288.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":11578.070,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":11578.070,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":11578.070,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":11578.070,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":11578.070,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":16556.640,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12094.860,"methodology":"fee schedule"},{"payer_name":"First Health","plan_name":"Exclusive","standard_charge_dollar":2258.000,"methodology":"per diem"},{"payer_name":"First Health","plan_name":"NonExclusive","standard_charge_dollar":2346.000,"methodology":"per diem"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":16723.880,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":62.00,"standard_charge_algorithm":"Reimbursement will be 62% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"SOUTHTEXASISDRATES","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":11168.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":13440.110,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":11168.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":11168.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":11168.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":11168.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":13440.110,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":12349.200,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":12747.570,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":14043.610,"methodology":"fee schedule"},{"payer_name":"MultiPlan","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":17560.070,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":11033.190,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":12279.770,"methodology":"fee schedule"},{"payer_name":"PPO Next/ Medical Control","plan_name":"COMMPPO","standard_charge_percentage":75.00,"standard_charge_algorithm":"Reimbursement will be 75% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":12279.770,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":11928.920,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":11928.920,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":11928.920,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":11928.920,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":11928.920,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":12513.670,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":18127.280,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":12279.770,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":12279.770,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":12279.770,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.000,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.000,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":11695.020,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":12279.770,"methodology":"fee schedule"},{"payer_name":"Texas Workforce Commission","plan_name":"WORKERSCOMP","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":11695.020,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9290.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $552131.00, reimbursement will be $6139 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalBenefitPlan","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11566.370,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":16.10,"standard_charge_algorithm":"Reimbursement will be 16.1% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":12630.620,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":11741.800,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of mandibular fracture; without manipulation ","code_information":[{"code":"21450","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":269.160,"maximum":7037.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":834.850,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1042.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1042.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1104.300,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1161.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":269.160,"methodology":"fee schedule"}]}]},{"description":"CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; duplication/deletion variants ","code_information":[{"code":"305","type":"RC"},{"code":"81222","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":372.770,"maximum":1226.900,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1226.900,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1226.900,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":435.070,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":372.770,"methodology":"fee schedule"}]}]},{"description":"RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC ","code_information":[{"code":"141","type":"RC"},{"code":"814","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated ","code_information":[{"code":"36478","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1199.900,"maximum":15410.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1411.640,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5237.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6540.220,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6540.220,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6928.200,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7288.470,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":9999.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":11331.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":13370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1199.900,"methodology":"fee schedule"}]}]},{"description":"KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC 4 Day Stay","code_information":[{"code":"143","type":"RC"},{"code":"488","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Optical coherence tomography of breast, surgical cavity; real-time intraoperative ","code_information":[{"code":"0353T","type":"CPT"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"REP INTRADISC ANNULUS;>1LEV ","code_information":[{"code":"0063T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC A 3 Day Stay","code_information":[{"code":"061","type":"MS-DRG"},{"code":"141","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Recement inlay onlay or part ","code_information":[{"code":"D2910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":493.270,"maximum":493.270,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":493.270,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":493.270,"methodology":"fee schedule"}]}]},{"description":"Membrane graft or membrane wrap, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"344","type":"RC"},{"code":"Q4205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with other than vein; femoral-anterior tibial, posterior tibial, or peroneal artery ","code_information":[{"code":"35666","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":17086.880,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":12465.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":15211.810,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":15211.810,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":16149.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17086.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"PLEURAL EFFUSION WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"120","type":"RC"},{"code":"188","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT 4 Day Stay","code_information":[{"code":"005","type":"MS-DRG"},{"code":"144","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Excision, trochanteric pressure ulcer, with primary suture; ","code_information":[{"code":"15950","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":521.990,"maximum":12635.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":614.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2594.210,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3239.340,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3239.340,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3431.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3609.940,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":521.990,"methodology":"fee schedule"}]}]},{"description":"MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"142","type":"MS-DRG"},{"code":"156","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Cystourethroscopy; with incision or resection of orifice of bladder diverticulum, single or multiple ","code_information":[{"code":"360","type":"RC"},{"code":"52305","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12635.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":2132.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":7997.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":9986.620,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":9986.620,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":10579.050,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11129.160,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1812.830,"methodology":"fee schedule"}]}]},{"description":"Lysis intranasal synechia ","code_information":[{"code":"30560","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":200.900,"maximum":5487.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":834.850,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1042.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1042.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1104.300,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1161.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":200.900,"methodology":"fee schedule"}]}]},{"description":"URETHRAL PROCEDURES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"126","type":"RC"},{"code":"672","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Revision, lower extremity arterial bypass, without thrombectomy, open; with segmental vein interposition ","code_information":[{"code":"35881","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3061.000,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC 4 Day Stay","code_information":[{"code":"067","type":"MS-DRG"},{"code":"119","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC A ","code_information":[{"code":"062","type":"MS-DRG"},{"code":"134","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Perineogram (eg, vaginogram, for sex determination or extent of anomalies) ","code_information":[{"code":"614","type":"RC"},{"code":"74775","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":234.730,"maximum":234.730,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":234.730,"methodology":"fee schedule"}]}]},{"description":"CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC 3 Day Stay","code_information":[{"code":"151","type":"RC"},{"code":"323","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC 3 Day Stay","code_information":[{"code":"164","type":"RC"},{"code":"315","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC ","code_information":[{"code":"157","type":"RC"},{"code":"390","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Transurethral destruction of prostate tissue; by radiofrequency thermotherapy ","code_information":[{"code":"53852","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":983.130,"maximum":3589.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3589.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2768.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2768.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":2630.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":3257.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1904.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":1022.850,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1092.370,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1092.370,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1092.370,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1092.370,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":983.130,"methodology":"fee schedule"}]}]},{"description":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETER 3 Day Stay","code_information":[{"code":"151","type":"RC"},{"code":"221","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC ","code_information":[{"code":"113","type":"RC"},{"code":"413","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND CO 3 Day Stay","code_information":[{"code":"164","type":"RC"},{"code":"809","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC 2 Day Stay","code_information":[{"code":"101","type":"RC"},{"code":"940","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC 4 Day Stay","code_information":[{"code":"086","type":"MS-DRG"},{"code":"151","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC Adult","code_information":[{"code":"823","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":41662.000,"maximum":55707.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":41662.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 20.4% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":47209.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 23.1% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":55707.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 27.3% of billable gross charges instead of the contracted rate."}]}]},{"description":"Proctopexy (eg, for prolapse); abdominal approach ","code_information":[{"code":"45540","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":14274.890,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10413.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12708.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12708.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13491.650,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14274.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"145","type":"RC"},{"code":"272","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC ","code_information":[{"code":"805","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.000,"maximum":19868.840,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":13060.640,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_dollar":9065.280,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_dollar":11331.600,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":13232.660,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":13894.290,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Averde Health","plan_name":"COMM","standard_charge_percentage":33.00,"standard_charge_algorithm":"Reimbursement will be 33% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8034.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":8343.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":8343.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":8859.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":13232.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":13232.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":13232.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9374.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13100.330,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13100.330,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":13100.330,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":13100.330,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":13100.330,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":18733.480,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12540.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"First Health","plan_name":"Exclusive","standard_charge_dollar":3695.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"First Health","plan_name":"NonExclusive","standard_charge_dollar":3844.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":18922.700,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":62.00,"standard_charge_algorithm":"Reimbursement will be 62% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"SOUTHTEXASISDRATES","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":12637.190,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":7504.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":12637.190,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":12637.190,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":12637.190,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":12637.190,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":7504.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":15038.650,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":14423.600,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":6834.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"MultiPlan","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":19868.840,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":10070.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":13894.290,"methodology":"fee schedule"},{"payer_name":"PPO Next/ Medical Control","plan_name":"COMMPPO","standard_charge_percentage":75.00,"standard_charge_algorithm":"Reimbursement will be 75% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":13894.290,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":13497.310,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":13497.310,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":13497.310,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":13497.310,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":13497.310,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":14158.950,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":13894.290,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":13894.290,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":13894.290,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.000,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.000,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":13232.660,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":13894.290,"methodology":"fee schedule"},{"payer_name":"Texas Workforce Commission","plan_name":"WORKERSCOMP","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13232.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"GlobalBenefitPlan","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13087.100,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":16.10,"standard_charge_algorithm":"Reimbursement will be 16.1% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":14291.270,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":1000.000,"methodology":"case rate"},{"payer_name":"USA Managed Care","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13285.590,"methodology":"fee schedule"}]}]},{"description":"NON-EXTENSIVE BURNS ","code_information":[{"code":"146","type":"RC"},{"code":"935","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC ","code_information":[{"code":"150","type":"RC"},{"code":"206","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Oncology, prostate cancer, mRNA expression assay of 12 genes (10 content and 2 housekeeping), RT-PCR test utilizing blood plasma and urine, algorithms to predict high-grade prostate cancer risk ","code_information":[{"code":"0011M","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":760.000,"maximum":760.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":760.000,"methodology":"fee schedule"}]}]},{"description":"MAJOR SKIN DISORDERS WITH MCC 4 Day Stay","code_information":[{"code":"128","type":"RC"},{"code":"595","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. 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"}]}]},{"description":"REMOVAL OF BREAST ","code_information":[{"code":"19220","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY ","code_information":[{"code":"207","type":"RC"},{"code":"934","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":28920.540,"maximum":28920.540,"payers_information":[{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":28920.540,"methodology":"fee schedule"}]}]},{"description":"LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC 4 Day Stay","code_information":[{"code":"121","type":"RC"},{"code":"417","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Thoracoscopy, surgical; with diagnostic wedge resection followed by anatomic lung resection (List separately in addition to code for primary procedure) ","code_information":[{"code":"32668","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1544.570,"maximum":12018.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1544.570,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1884.900,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1884.900,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":2001.070,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2117.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"DIABETES WITH MCC 3 Day Stay","code_information":[{"code":"123","type":"RC"},{"code":"637","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC 3 Day Stay","code_information":[{"code":"082","type":"MS-DRG"},{"code":"167","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Injection, lecanemab-irmb, 1 mg ","code_information":[{"code":"J0174","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1.330,"maximum":3.480,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":2.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":2.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":2.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3.040,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2.590,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":2.950,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3.480,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":1.330,"methodology":"fee schedule"}]}]},{"description":"PANCREAS TRANSPLANT ","code_information":[{"code":"010","type":"MS-DRG"},{"code":"118","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZA 3 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"217","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"FRACTURES OF FEMUR WITHOUT MCC 2 Day Stay","code_information":[{"code":"137","type":"RC"},{"code":"534","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"ANAL AND STOMAL PROCEDURES WITH CC ","code_information":[{"code":"153","type":"RC"},{"code":"348","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Revision (including removal) of prosthetic vaginal graft; open abdominal approach ","code_information":[{"code":"499","type":"RC"},{"code":"57296","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":12544.680,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9151.610,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11168.060,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11168.060,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":11856.370,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12544.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood); physician interpretation and report, when required ","code_information":[{"code":"311","type":"RC"},{"code":"86153","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":96.670,"maximum":96.670,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":96.670,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":96.670,"methodology":"fee schedule"}]}]},{"description":"FRACTURES OF HIP AND PELVIS WITHOUT MCC ","code_information":[{"code":"169","type":"RC"},{"code":"536","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"MAJOR CHEST PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"130","type":"RC"},{"code":"165","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"ACUTE LEUKEMIA WITH MCC 4 Day Stay","code_information":[{"code":"117","type":"RC"},{"code":"834","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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"}]}]},{"description":"Tracheostomy, emergency procedure; cricothyroid membrane ","code_information":[{"code":"31605","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":93.970,"maximum":5055.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":110.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":384.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":480.590,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":480.590,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":509.100,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":535.570,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2251.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2650.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":93.970,"methodology":"fee schedule"}]}]},{"description":"PULMONARY EDEMA AND RESPIRATORY FAILURE 2 Day Stay","code_information":[{"code":"131","type":"RC"},{"code":"189","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"MAJOR BLADDER PROCEDURES WITH MCC 4 Day Stay","code_information":[{"code":"118","type":"RC"},{"code":"653","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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"}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC 4 Day Stay","code_information":[{"code":"064","type":"MS-DRG"},{"code":"144","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"MINOR BLADDER PROCEDURES WITH MCC 3 Day Stay","code_information":[{"code":"122","type":"RC"},{"code":"662","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"147","type":"RC"},{"code":"446","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC ","code_information":[{"code":"117","type":"RC"},{"code":"273","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"Amniocore, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"343","type":"RC"},{"code":"Q4227","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"Storage (per year); embryo(s) ","code_information":[{"code":"300","type":"RC"},{"code":"89342","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":149.160,"maximum":149.160,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":149.160,"methodology":"fee schedule"}]}]},{"description":"RENAL FAILURE WITH MCC 2 Day Stay","code_information":[{"code":"101","type":"RC"},{"code":"682","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Colectomy, partial; with coloproctostomy (low pelvic anastomosis), with colostomy ","code_information":[{"code":"44146","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":28615.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":20875.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":25474.870,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":25474.870,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":27044.930,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":28615.000,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, each additional lesion (List separately in addition to code for primary procedure) ","code_information":[{"code":"96935","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":192.990,"maximum":454.970,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":192.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":235.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":235.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":250.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":264.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":454.970,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":454.970,"methodology":"fee schedule"}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC 2 Day Stay","code_information":[{"code":"118","type":"RC"},{"code":"742","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Injection, calcitonin salmon, up to 400 units ","code_information":[{"code":"344","type":"RC"},{"code":"J0630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2364.780,"maximum":2364.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2364.780,"methodology":"fee schedule"}]}]},{"description":"Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed ","code_information":[{"code":"480","type":"RC"},{"code":"93453","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10342.000,"maximum":17384.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":17384.000,"methodology":"case rate"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":10342.000,"methodology":"case rate"}]}]},{"description":"MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC ","code_information":[{"code":"116","type":"RC"},{"code":"448","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"CONCUSSION WITH CC ","code_information":[{"code":"089","type":"MS-DRG"},{"code":"137","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"INTRAOCULAR PROCEDURES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"117","type":"MS-DRG"},{"code":"152","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Closure of rectourethral fistula; with colostomy ","code_information":[{"code":"367","type":"RC"},{"code":"45825","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC ","code_information":[{"code":"147","type":"RC"},{"code":"629","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC 3 Day Stay","code_information":[{"code":"142","type":"RC"},{"code":"259","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Excision of hyperplastic alveolar mucosa, each quadrant (specify) ","code_information":[{"code":"41828","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":202.600,"maximum":7227.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1346.370,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1642.790,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1642.790,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1744.620,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1846.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":202.600,"methodology":"fee schedule"}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM O.R. 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"}]}]},{"description":"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHE 4 Day Stay","code_information":[{"code":"041","type":"MS-DRG"},{"code":"133","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOU ","code_information":[{"code":"157","type":"RC"},{"code":"641","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"139","type":"RC"},{"code":"145","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS 2 Day Stay","code_information":[{"code":"019","type":"MS-DRG"},{"code":"156","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"148","type":"RC"},{"code":"578","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"MAJOR CHEST PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"113","type":"RC"},{"code":"165","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"SALIVARY GLAND PROCEDURES ","code_information":[{"code":"119","type":"RC"},{"code":"139","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC A ","code_information":[{"code":"062","type":"MS-DRG"},{"code":"142","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"APPENDIX PROCEDURES WITH MCC 4 Day Stay","code_information":[{"code":"126","type":"RC"},{"code":"397","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"158","type":"RC"},{"code":"825","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Craniotomy with elevation of bone flap; for partial or subtotal (functional) hemispherectomy ","code_information":[{"code":"360","type":"RC"},{"code":"61543","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":28782.830,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":20997.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":25624.280,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":25624.280,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":27203.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":28782.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Level 3 Type B ED Visits ","code_information":[{"code":"05033","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":164.890,"maximum":164.890,"payers_information":[{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":164.890,"methodology":"fee schedule"}]}]},{"description":"Urography, retrograde, with or without KUB ","code_information":[{"code":"351","type":"RC"},{"code":"74420","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":78.730,"maximum":78.730,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":78.730,"methodology":"fee schedule"}]}]},{"description":"DIABETES WITH MCC ","code_information":[{"code":"112","type":"RC"},{"code":"637","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY ","code_information":[{"code":"129","type":"RC"},{"code":"934","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Adenoidectomy, primary; younger than age 12 ","code_information":[{"code":"369","type":"RC"},{"code":"42830","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":951.370,"maximum":12635.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1119.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4950.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6181.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6181.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6548.230,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6888.730,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":951.370,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography, pelvis, with or without contrast material(s) ","code_information":[{"code":"618","type":"RC"},{"code":"72198","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":672.030,"maximum":3090.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3090.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2385.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2385.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":2265.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":2807.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1641.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":672.030,"methodology":"fee schedule"}]}]},{"description":"Suture of nerve; requiring shortening of bone of extremity (List separately in addition to code for nerve suture) ","code_information":[{"code":"64876","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1672.000,"maximum":5055.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel ","code_information":[{"code":"403","type":"RC"},{"code":"77770","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":984.060,"maximum":984.060,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":984.060,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":984.060,"methodology":"fee schedule"}]}]},{"description":"HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC 4 Day Stay","code_information":[{"code":"164","type":"RC"},{"code":"421","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH ","code_information":[{"code":"127","type":"RC"},{"code":"618","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"128","type":"RC"},{"code":"561","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC 4 Day Stay","code_information":[{"code":"085","type":"MS-DRG"},{"code":"128","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Helicobacter pylori, blood test analysis for urease activity, non-radioactive isotope (eg, C-13) ","code_information":[{"code":"83009","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":56.010,"maximum":246.040,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":67.930,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":61.110,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":67.360,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":70.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":154.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":187.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":187.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":200.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":67.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":67.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":67.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":211.510,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":183.880,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":208.830,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":246.040,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":67.360,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":67.360,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":67.360,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":67.360,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":67.360,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":133.370,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":58.280,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":134.720,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":202.070,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":67.360,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":67.360,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":67.360,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":67.360,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":67.360,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":67.360,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":73.420,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":62.240,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":163.680,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":62.240,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":62.240,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":62.240,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":141.460,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":158.300,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":70.730,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":70.730,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":71.400,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":71.400,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":71.400,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":71.400,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":71.400,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":70.730,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":104.410,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":70.730,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":70.730,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":70.730,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":56.010,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":72.900,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":67.360,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":68.710,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":80.830,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":66.010,"methodology":"fee schedule"}]}]},{"description":"Colonoscopy through stoma; 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with anesthesia ","code_information":[{"code":"27095","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":5841.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"MALIGNANT BREAST DISORDERS WITH CC ","code_information":[{"code":"155","type":"RC"},{"code":"598","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"VIRAL MENINGITIS WITH CC/MCC 4 Day Stay","code_information":[{"code":"075","type":"MS-DRG"},{"code":"136","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Transcranial Doppler study of the intracranial arteries; venous-arterial shunt detection with intravenous microbubble injection ","code_information":[{"code":"352","type":"RC"},{"code":"93893","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":111.150,"maximum":111.150,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":111.150,"methodology":"fee schedule"}]}]},{"description":"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES 2 Day Stay","code_information":[{"code":"154","type":"RC"},{"code":"844","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH 3 Day Stay","code_information":[{"code":"123","type":"RC"},{"code":"544","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Calculus; X-ray diffraction ","code_information":[{"code":"319","type":"RC"},{"code":"82370","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.730,"maximum":43.600,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":43.600,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":43.600,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":10.730,"methodology":"fee schedule"}]}]},{"description":"Injection, sulfamethoxazole and trimethoprim, 10 ml ","code_information":[{"code":"S0039","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":14.650,"maximum":149.520,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":14.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":17.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":17.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":18.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20.110,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":149.520,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":149.520,"methodology":"fee schedule"}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHE 4 Day Stay","code_information":[{"code":"141","type":"RC"},{"code":"838","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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"}]}]},{"description":"Injection, ethacrynate sodium, 1 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J1807","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":21.250,"maximum":21.250,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":21.250,"methodology":"fee schedule"}]}]},{"description":"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC ","code_information":[{"code":"152","type":"RC"},{"code":"538","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":5054.650,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5317.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case 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(in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Euglobulin lysis 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"}]}]},{"description":"MALIGNANT BREAST DISORDERS WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"128","type":"RC"},{"code":"599","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; variants in exon 2 (eg, codons 12 and 13) ","code_information":[{"code":"306","type":"RC"},{"code":"81275","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":165.580,"maximum":544.960,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":544.960,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":544.960,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":193.250,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":165.580,"methodology":"fee schedule"}]}]},{"description":"Morphometric analysis; nerve ","code_information":[{"code":"312","type":"RC"},{"code":"88356","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":49.760,"maximum":612.590,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":612.590,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":612.590,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":49.760,"methodology":"fee schedule"}]}]},{"description":"AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC ","code_information":[{"code":"017","type":"MS-DRG"},{"code":"154","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Valvuloplasty, aortic valve, open, with cardiopulmonary bypass; simple (ie, valvotomy, debridement, debulking, and/or simple commissural resuspension) ","code_information":[{"code":"33390","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Beta-amyloid; 1-40 (Abeta 40) ","code_information":[{"code":"301","type":"RC"},{"code":"82233","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":128.920,"maximum":128.920,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":128.920,"methodology":"fee schedule"}]}]},{"description":"Platelet, aggregation (in vitro), each agent ","code_information":[{"code":"310","type":"RC"},{"code":"85576","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.340,"maximum":74.790,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":74.790,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":74.790,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":21.340,"methodology":"fee schedule"}]}]},{"description":"TRAUMATIC INJURY WITHOUT MCC 2 Day Stay","code_information":[{"code":"157","type":"RC"},{"code":"914","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of bone for decompression ","code_information":[{"code":"362","type":"RC"},{"code":"67414","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SKIN GRAFTS FOR INJURIES WITH CC/MCC 2 Day Stay","code_information":[{"code":"110","type":"RC"},{"code":"904","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR 4 Day Stay","code_information":[{"code":"160","type":"RC"},{"code":"276","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC 2 Day Stay","code_information":[{"code":"128","type":"RC"},{"code":"656","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"CERVICAL SPINAL FUSION WITH CC 3 Day Stay","code_information":[{"code":"153","type":"RC"},{"code":"472","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm) ","code_information":[{"code":"403","type":"RC"},{"code":"77605","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2275.430,"maximum":2275.430,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":2275.430,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":2275.430,"methodology":"fee schedule"}]}]},{"description":"SEPTIC ARTHRITIS WITH CC 4 Day Stay","code_information":[{"code":"132","type":"RC"},{"code":"549","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"OTHER O.R. 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"}]}]},{"description":"HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC 3 Day Stay","code_information":[{"code":"101","type":"RC"},{"code":"421","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3025.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "}]}]},{"description":"Creatine kinase (CK), (CPK); total ","code_information":[{"code":"309","type":"RC"},{"code":"82550","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.580,"maximum":22.670,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":22.670,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":22.670,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6.510,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":5.580,"methodology":"fee schedule"}]}]},{"description":"Biopsy of vulva or perineum (separate procedure); each separate additional lesion (List separately in addition to code for primary procedure) ","code_information":[{"code":"56606","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1422.000,"maximum":2678.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":2678.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1964.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":2433.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1422.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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"}]}]},{"description":"Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes ","code_information":[{"code":"305","type":"RC"},{"code":"89280","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":656.150,"maximum":656.150,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":656.150,"methodology":"fee schedule"}]}]},{"description":"Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); lumbar ","code_information":[{"code":"22207","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3061.000,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC ","code_information":[{"code":"128","type":"RC"},{"code":"872","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Oncology (solid tumor), mass spectrometric 30 protein targets, formalin-fixed paraffin-embedded tissue, prognostic and predictive algorithm reported as likely, unlikely, or uncertain benefit of 39 che ","code_information":[{"code":"0174U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1305.370,"maximum":1305.370,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1305.370,"methodology":"fee schedule"}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC ","code_information":[{"code":"095","type":"MS-DRG"},{"code":"169","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Fetal chromosomal aneuploidy (eg, trisomy 21, monosomy X) genomic sequence analysis panel, circulating cell-free fetal DNA in maternal blood, must include analysis of chromosomes 13, 18, and 21 ","code_information":[{"code":"81420","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":650.350,"maximum":759.050,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":759.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":650.350,"methodology":"fee schedule"}]}]},{"description":"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC ","code_information":[{"code":"124","type":"RC"},{"code":"308","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC ","code_information":[{"code":"123","type":"RC"},{"code":"281","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC ","code_information":[{"code":"164","type":"RC"},{"code":"519","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Oncology (colorectal) screening, quantitative real-time target and signal amplification of 8 RNA markers and fecal hemoglobin, algorithm reported as a positive or negative for colorectal cancer risk ","code_information":[{"code":"0421U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":508.870,"maximum":508.870,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":508.870,"methodology":"fee schedule"}]}]},{"description":"PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC ","code_information":[{"code":"160","type":"RC"},{"code":"274","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"156","type":"RC"},{"code":"816","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"154","type":"RC"},{"code":"983","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"142","type":"RC"},{"code":"858","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC 2 Day Stay","code_information":[{"code":"110","type":"RC"},{"code":"350","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Isolation- tooth w rubb dam ","code_information":[{"code":"790","type":"RC"},{"code":"D3910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC ","code_information":[{"code":"013","type":"MS-DRG"},{"code":"116","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Implantation of non-biologic or synthetic implant (eg, polypropylene) for fascial reinforcement of the abdominal wall (List separately in addition to code for primary procedure) ","code_information":[{"code":"0437T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1672.000,"maximum":2940.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"CELLULITIS WITHOUT MCC ","code_information":[{"code":"155","type":"RC"},{"code":"603","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"135","type":"RC"},{"code":"839","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"169","type":"RC"},{"code":"708","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Bone graft, any donor area; major or large ","code_information":[{"code":"20902","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15732.530,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11305.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14954.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15732.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case 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for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":10674.090,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":11331.950,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11989.820,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health 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adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":22680.810,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":24078.670,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25476.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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","code_information":[{"code":"0102T","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":13370.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":9999.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":11331.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":13370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open femoral artery exposure with creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by groin incision, unilateral (List separately in addition ","code_information":[{"code":"34714","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1672.000,"maximum":5841.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC ","code_information":[{"code":"125","type":"RC"},{"code":"419","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Venipuncture, cutdown; age 1 or over ","code_information":[{"code":"36425","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":687.190,"maximum":5055.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":687.190,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":858.070,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":858.070,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":908.970,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":956.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"132","type":"RC"},{"code":"285","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES 3 Day Stay","code_information":[{"code":"121","type":"RC"},{"code":"278","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC 4 Day Stay","code_information":[{"code":"128","type":"RC"},{"code":"191","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Excision of extensor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod ","code_information":[{"code":"26415","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15410.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1373.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS ","code_information":[{"code":"149","type":"RC"},{"code":"207","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; arterial anastomosis, each ","code_information":[{"code":"360","type":"RC"},{"code":"50328","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12018.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1874.600,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":2287.640,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":2287.640,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":2428.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2569.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 2 Day Stay","code_information":[{"code":"116","type":"RC"},{"code":"981","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Pneumococcal conjugate vaccine, 15 valent (PCV15), for intramuscular use ","code_information":[{"code":"110373","type":"CDM"},{"code":"90671","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":261.150,"maximum":672.550,"gross_charge":754.56,"discounted_cash":754.56,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_percentage":8.07,"standard_charge_algorithm":"Reimbursement will be 8.07% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":418.920,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":510.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":510.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":542.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":575.080,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":500.560,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":569.870,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":672.550,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_percentage":15.84,"standard_charge_algorithm":"Reimbursement will be 15.84% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_percentage":16.00,"standard_charge_algorithm":"Reimbursement will be 16% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_percentage":8.72,"standard_charge_algorithm":"Reimbursement will be 8.72% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":19.44,"standard_charge_algorithm":"Reimbursement will be 19.44% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_percentage":16.80,"standard_charge_algorithm":"Reimbursement will be 16.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_percentage":8.48,"standard_charge_algorithm":"Reimbursement will be 8.48% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_percentage":8.48,"standard_charge_algorithm":"Reimbursement will be 8.48% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_percentage":8.48,"standard_charge_algorithm":"Reimbursement will be 8.48% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_percentage":8.48,"standard_charge_algorithm":"Reimbursement will be 8.48% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_percentage":8.48,"standard_charge_algorithm":"Reimbursement will be 8.48% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior","plan_name":"HIX","standard_charge_percentage":12.40,"standard_charge_algorithm":"Reimbursement will be 12.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":261.150,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_percentage":8.16,"standard_charge_algorithm":"Reimbursement will be 8.16% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_percentage":9.60,"standard_charge_algorithm":"Reimbursement will be 9.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_percentage":7.84,"standard_charge_algorithm":"Reimbursement will be 7.84% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"PERCUT VERTEBROPLASTY ADDL ","code_information":[{"code":"22522","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC 2 Day Stay","code_information":[{"code":"140","type":"RC"},{"code":"322","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"ACUTE AND SUBACUTE ENDOCARDITIS WITH CC ","code_information":[{"code":"128","type":"RC"},{"code":"289","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) ","code_information":[{"code":"362","type":"RC"},{"code":"46924","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2946.000,"maximum":5055.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC 2 Day Stay","code_information":[{"code":"149","type":"RC"},{"code":"970","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Venography, caval, inferior, with serialography, radiological supervision and interpretation ","code_information":[{"code":"359","type":"RC"},{"code":"75825","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":116.570,"maximum":116.570,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":116.570,"methodology":"fee schedule"}]}]},{"description":"MINOR SKIN DISORDERS WITHOUT MCC 2 Day Stay","code_information":[{"code":"136","type":"RC"},{"code":"607","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"FRACTURES OF FEMUR WITHOUT MCC 4 Day Stay","code_information":[{"code":"117","type":"RC"},{"code":"534","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCE ","code_information":[{"code":"123","type":"RC"},{"code":"830","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC 3 Day Stay","code_information":[{"code":"154","type":"RC"},{"code":"576","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHE ","code_information":[{"code":"838","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8115.070,"maximum":8115.070,"payers_information":[{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":8115.070,"methodology":"fee schedule"}]}]},{"description":"Lymphangiography, extremity only, bilateral, radiological supervision and interpretation ","code_information":[{"code":"351","type":"RC"},{"code":"75803","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":305.590,"maximum":305.590,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":305.590,"methodology":"fee schedule"}]}]},{"description":"MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC ","code_information":[{"code":"058","type":"MS-DRG"},{"code":"122","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal joint, each ","code_information":[{"code":"26080","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2434.000,"maximum":2434.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC Pediatric","code_information":[{"code":"143","type":"RC"},{"code":"754","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":18524.000,"maximum":24768.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":18524.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":20991.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":24768.000,"methodology":"case rate"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH MCC ","code_information":[{"code":"0DL64CZ","type":"ICD"},{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2950.000,"maximum":2950.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2950.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"Tympanic neurectomy High Cost Surgery","code_information":[{"code":"361","type":"RC"},{"code":"69676","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2369.000,"maximum":2369.000,"payers_information":[{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":2369.000,"methodology":"case rate"}]}]},{"description":"Venography, extremity, bilateral, radiological supervision and interpretation ","code_information":[{"code":"611","type":"RC"},{"code":"75822","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":135.650,"maximum":135.650,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":135.650,"methodology":"fee schedule"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC ","code_information":[{"code":"133","type":"RC"},{"code":"565","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Blood smear, peripheral, interpretation by physician with written report ","code_information":[{"code":"304","type":"RC"},{"code":"85060","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.770,"maximum":70.160,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":70.160,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":70.160,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":24.770,"methodology":"fee schedule"}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC 4 Day Stay","code_information":[{"code":"115","type":"RC"},{"code":"498","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"152","type":"RC"},{"code":"440","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC 3 Day Stay","code_information":[{"code":"126","type":"RC"},{"code":"277","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Venography, orbital, radiological supervision and interpretation ","code_information":[{"code":"323","type":"RC"},{"code":"75880","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":110.760,"maximum":1218.650,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":376.710,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":376.710,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1218.650,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":110.760,"methodology":"fee schedule"}]}]},{"description":"Repair of large omphalocele or gastroschisis; with removal of prosthesis, final reduction and closure, in operating room ","code_information":[{"code":"490","type":"RC"},{"code":"49606","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15347.490,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11196.310,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":13663.300,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":13663.300,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14505.390,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15347.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"130","type":"RC"},{"code":"387","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"URETHRAL PROCEDURES WITH CC/MCC 2 Day Stay","code_information":[{"code":"133","type":"RC"},{"code":"671","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC 2 Day Stay","code_information":[{"code":"130","type":"RC"},{"code":"242","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Esophageal mucosal integrity testing by electrical impedance, transoral, includes esophagoscopy or esophagogastroduodenoscopy ","code_information":[{"code":"790","type":"RC"},{"code":"C9777","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4807.000,"maximum":12635.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"}]}]},{"description":"Trismus appliance ","code_information":[{"code":"481","type":"RC"},{"code":"D5937","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal with autograft (other than first toe) ","code_information":[{"code":"28307","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2573.700,"maximum":15732.530,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":3027.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11305.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14954.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15732.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2573.700,"methodology":"fee schedule"}]}]},{"description":"AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC Pediatric","code_information":[{"code":"153","type":"RC"},{"code":"476","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":31855.000,"maximum":42593.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":31855.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":36096.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":42593.000,"methodology":"case rate"}]}]},{"description":"MEDICAL BACK PROBLEMS WITHOUT MCC 3 Day Stay","code_information":[{"code":"129","type":"RC"},{"code":"552","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; initiation, veno-arterial ","code_information":[{"code":"33947","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MAJOR MALE PELVIC PROCEDURES WITH CC/MCC Pediatric","code_information":[{"code":"123","type":"RC"},{"code":"707","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":21261.000,"maximum":28429.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":21261.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":24092.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28429.000,"methodology":"case rate"}]}]},{"description":"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"121","type":"RC"},{"code":"328","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Total thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy ","code_information":[{"code":"362","type":"RC"},{"code":"60225","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Wheelchair accessory, power seating system, recline only, with mechanical shear reduction ","code_information":[{"code":"E1004","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":584.300,"maximum":1448.810,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":601.290,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":596.220,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":626.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":596.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":596.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":596.220,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":596.220,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":596.220,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":596.220,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":596.220,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":596.220,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":1180.520,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":1192.440,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":596.220,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":596.220,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":596.220,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":596.220,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":596.220,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":596.220,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":649.880,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":1448.810,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":1252.060,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":626.030,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":626.030,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":631.990,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":631.990,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":631.990,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":631.990,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":631.990,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":626.030,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":924.140,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":626.030,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":626.030,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":626.030,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":596.220,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":596.220,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":608.140,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":715.460,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":584.300,"methodology":"fee schedule"}]}]},{"description":"OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC 3 Day Stay","code_information":[{"code":"120","type":"RC"},{"code":"315","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Cystourethroscopy with ureteroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, electrocautery, and incision) ","code_information":[{"code":"52344","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1226.380,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5705.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7123.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7123.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7546.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7938.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1226.380,"methodology":"fee schedule"}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC 3 Day Stay","code_information":[{"code":"141","type":"RC"},{"code":"964","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC 3 Day Stay","code_information":[{"code":"083","type":"MS-DRG"},{"code":"118","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"130","type":"RC"},{"code":"825","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"AFTERCARE WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"142","type":"RC"},{"code":"950","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"COMPLICATED PEPTIC ULCER WITH MCC 3 Day Stay","code_information":[{"code":"139","type":"RC"},{"code":"380","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC 2 Day Stay","code_information":[{"code":"134","type":"RC"},{"code":"958","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Lapscp retroperit LN Bx ","code_information":[{"code":"361","type":"RC"},{"code":"56311","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"Multiple osteotomies with realignment on intramedullary rod, humeral shaft (Sofield type procedure) ","code_information":[{"code":"24410","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":595.000,"maximum":5292.120,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5069.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3911.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3911.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3716.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4601.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2692.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":4955.350,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":5292.120,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":5292.120,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":5292.120,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":5292.120,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":4762.910,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":595.000,"methodology":"case rate"}]}]},{"description":"PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC 2 Day Stay","code_information":[{"code":"111","type":"RC"},{"code":"250","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"ATHERECTOMY, OPEN ","code_information":[{"code":"35484","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"113","type":"RC"},{"code":"761","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Excision of bone (eg, for osteomyelitis or bone abscess); mandible ","code_information":[{"code":"21025","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12756.890,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9167.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11447.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11447.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12126.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12756.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2096.960,"methodology":"fee schedule"}]}]},{"description":"MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"151","type":"RC"},{"code":"508","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Endoscopy, surgical, including video-assisted harvest of vein(s) for coronary artery bypass procedure (List separately in addition to code for primary procedure) ","code_information":[{"code":"33508","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":5841.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"Antibody; Yersinia ","code_information":[{"code":"307","type":"RC"},{"code":"86793","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.300,"maximum":45.910,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":45.910,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":45.910,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.190,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":11.300,"methodology":"fee schedule"}]}]},{"description":"REVISION OF HIP OR KNEE REPLACEMENT WITH MCC 2 Day Stay","code_information":[{"code":"129","type":"RC"},{"code":"466","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"ATHEROSCLEROSIS WITH MCC ","code_information":[{"code":"160","type":"RC"},{"code":"302","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"123","type":"RC"},{"code":"349","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"KIDNEY AND URINARY TRACT NEOPLASMS WITH CC ","code_information":[{"code":"160","type":"RC"},{"code":"687","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2958.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"}]}]},{"description":"Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; laparoscopic ","code_information":[{"code":"0585T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":13988.660,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10205.020,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12453.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12453.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13221.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13988.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"HEADACHES WITHOUT MCC 2 Day Stay","code_information":[{"code":"103","type":"MS-DRG"},{"code":"147","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC ","code_information":[{"code":"100","type":"RC"},{"code":"195","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 3 Day Stay","code_information":[{"code":"155","type":"RC"},{"code":"987","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC 3 Day Stay","code_information":[{"code":"100","type":"RC"},{"code":"660","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"FRACTURE OF LOWER EXTREMITY; M > 28.15 & M < 34.15 ","code_information":[{"code":"118","type":"RC"},{"code":"B0703","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":32025.550,"maximum":34907.850,"payers_information":[{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":32025.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":32025.550,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":34907.850,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":33626.830,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":32666.070,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":32666.070,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":32666.070,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":32666.070,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":32666.070,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":33626.830,"methodology":"fee schedule"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"125","type":"RC"},{"code":"819","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"TRANSURETHRAL PROCEDURES WITH MCC ","code_information":[{"code":"153","type":"RC"},{"code":"668","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"093","type":"MS-DRG"},{"code":"118","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Vasography, vesiculography, or epididymography, radiological supervision and interpretation ","code_information":[{"code":"404","type":"RC"},{"code":"74440","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":99.510,"maximum":99.510,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":99.510,"methodology":"fee schedule"}]}]},{"description":"Introduction of long gastrointestinal tube (eg, Miller-Abbott) (separate procedure) ","code_information":[{"code":"44500","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":359.420,"maximum":5055.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1485.390,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1854.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1854.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1964.800,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2066.970,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2251.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2527.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2650.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":359.420,"methodology":"fee schedule"}]}]},{"description":"Non-sheet form skin substitute, fda cleared as a device, not otherwise specified (list in addition to primary procedure) ","code_information":[{"code":"343","type":"RC"},{"code":"A4100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.980,"maximum":209.980,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.980,"methodology":"fee schedule"}]}]},{"description":"ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC 3 Day Stay","code_information":[{"code":"157","type":"RC"},{"code":"288","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"VENTRICULAR SHUNT PROCEDURES WITH CC Pediatric","code_information":[{"code":"032","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":36906.940,"maximum":47455.260,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":36906.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":41503.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":41503.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":44480.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":47455.260,"methodology":"fee schedule"}]}]},{"description":"Excision, coccygeal pressure ulcer, with coccygectomy; with flap closure ","code_information":[{"code":"15922","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":595.000,"maximum":5069.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5069.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3911.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3911.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3716.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4601.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2692.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":1501.350,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1603.380,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1603.380,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1603.380,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1603.380,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":1443.040,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":595.000,"methodology":"case rate"}]}]},{"description":"MAJOR CHEST PROCEDURES WITH MCC 3 Day Stay","code_information":[{"code":"160","type":"RC"},{"code":"163","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"KIDNEY TRANSPLANT ","code_information":[{"code":"152","type":"RC"},{"code":"652","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC ","code_information":[{"code":"110","type":"RC"},{"code":"626","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Injection, calcitriol, 0.1 mcg ","drug_information":{"unit":1.000000000000000e+000,"type":"GM"},"code_information":[{"code":"110469","type":"CDM"},{"code":"J0636","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1.270,"maximum":7.630,"gross_charge":51.18,"discounted_cash":51.18,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1.270,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1.640,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1.740,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":1.970,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":2.240,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":2.650,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":7.630,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":7.630,"methodology":"fee schedule"}]}]},{"description":"BRONCHOSCOPY INJ FOR X-RAY ","code_information":[{"code":"31656","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"Osteoplasty, tibia and fibula, lengthening or shortening ","code_information":[{"code":"27715","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4988.000,"maximum":15581.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10505.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12820.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12820.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13610.640,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14400.800,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"}]}]},{"description":"INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC ","code_information":[{"code":"020","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.000,"maximum":282532.000,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":66450.450,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_dollar":66097.920,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_dollar":82622.400,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":67325.680,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":70691.960,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 8. "},{"payer_name":"Averde Health","plan_name":"COMM","standard_charge_percentage":33.00,"standard_charge_algorithm":"Reimbursement will be 33% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":163345.270,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":181393.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":181393.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":182954.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":67325.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":67325.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":67325.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":184515.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":66652.420,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":66652.420,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":66652.420,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":66652.420,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":66652.420,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":95312.970,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":107393.380,"methodology":"fee schedule"},{"payer_name":"First Health","plan_name":"Exclusive","standard_charge_dollar":2258.000,"methodology":"per diem"},{"payer_name":"First Health","plan_name":"NonExclusive","standard_charge_dollar":2346.000,"methodology":"per diem"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":96275.720,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":62.00,"standard_charge_algorithm":"Reimbursement will be 62% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"SOUTHTEXASISDRATES","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":64296.020,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":119338.220,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":64296.020,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":64296.020,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":64296.020,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":64296.020,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":119338.220,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":109651.730,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":73384.990,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":124696.870,"methodology":"fee schedule"},{"payer_name":"MultiPlan","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":101089.510,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":97966.560,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":70691.960,"methodology":"fee schedule"},{"payer_name":"PPO Next/ Medical Control","plan_name":"COMMPPO","standard_charge_percentage":75.00,"standard_charge_algorithm":"Reimbursement will be 75% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":70691.960,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":68672.190,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":68672.190,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":68672.190,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":68672.190,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":68672.190,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":72038.480,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":104354.800,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":70691.960,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":70691.960,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":70691.960,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.000,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.000,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":67325.680,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":70691.960,"methodology":"fee schedule"},{"payer_name":"Texas Workforce Commission","plan_name":"WORKERSCOMP","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":67325.680,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":282532.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 16. "},{"payer_name":"United","plan_name":"GlobalBenefitPlan","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":67594.980,"methodology":"fee schedule"}]}]},{"description":"Osteotomy, femur, shaft or supracondylar; with fixation ","code_information":[{"code":"27450","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15581.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9968.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12164.540,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12164.540,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12914.270,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13663.990,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"}]}]},{"description":"Cytopathology, evaluation of fine needle aspirate; interpretation and report ","code_information":[{"code":"310","type":"RC"},{"code":"88173","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":49.760,"maximum":426.070,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":426.070,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":426.070,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":49.760,"methodology":"fee schedule"}]}]},{"description":"ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC ","code_information":[{"code":"139","type":"RC"},{"code":"266","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC 3 Day Stay","code_information":[{"code":"112","type":"RC"},{"code":"513","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"MALIGNANT BREAST DISORDERS WITH MCC ","code_information":[{"code":"120","type":"RC"},{"code":"597","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"ALLOGENEIC BONE MARROW TRANSPLANT ","code_information":[{"code":"014","type":"MS-DRG"},{"code":"143","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"CESAREAN SECTION WITH STERILIZATION WITH CC ","code_information":[{"code":"10D00Z1","type":"ICD"},{"code":"152","type":"RC"},{"code":"784","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7586.000,"maximum":14288.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":14288.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":11025.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":11025.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":10475.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":12969.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":7586.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"118","type":"RC"},{"code":"761","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS 2 Day Stay","code_information":[{"code":"146","type":"RC"},{"code":"208","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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"}]}]},{"description":"RECTAL RESECTION WITH MCC 2 Day Stay","code_information":[{"code":"134","type":"RC"},{"code":"332","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Cerebrospinal fluid flow, imaging (not including introduction of material); ventriculography ","code_information":[{"code":"343","type":"RC"},{"code":"78635","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":338.770,"maximum":1043.460,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1043.460,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1043.460,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":338.770,"methodology":"fee schedule"}]}]},{"description":"INFECTIOUS AND PARASITIC DISEASES WITH O.R. 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"}]}]},{"description":"PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC 2 Day Stay","code_information":[{"code":"068","type":"MS-DRG"},{"code":"135","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"HYPERTENSION WITH MCC 2 Day Stay","code_information":[{"code":"121","type":"RC"},{"code":"304","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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"}]}]},{"description":"Arthroscopy, elbow, surgical; debridement, limited ","code_information":[{"code":"29837","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC A 4 Day Stay","code_information":[{"code":"063","type":"MS-DRG"},{"code":"153","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":143.480,"methodology":"fee schedule"}]}]},{"description":"Ureteral reflux study (radiopharmaceutical voiding cystogram) ","code_information":[{"code":"359","type":"RC"},{"code":"78740","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":221.190,"maximum":221.190,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":221.190,"methodology":"fee schedule"}]}]},{"description":"Replantation, forearm (includes 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":41823.540,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":44251.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":272.570,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":286.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Strabismus surgery on patient with scarring of extraocular muscles (eg, prior ocular injury, strabismus or retinal detachment surgery) or restrictive myopathy (eg, dysthyroid ophthalmopathy) (List sep ","code_information":[{"code":"360","type":"RC"},{"code":"67332","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":5841.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"Reoperation, femoral-popliteal or femoral (popliteal)-anterior tibial, posterior tibial, peroneal artery, or other distal vessels, more than 1 month after original operation (List separately in additi ","code_information":[{"code":"35700","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12018.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1503.700,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1835.020,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1835.020,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1948.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2061.210,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 4 Day Stay","code_information":[{"code":"118","type":"RC"},{"code":"345","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC 2 Day Stay","code_information":[{"code":"131","type":"RC"},{"code":"755","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Excision or fulguration; urethral caruncle ","code_information":[{"code":"480","type":"RC"},{"code":"53265","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3041.000,"maximum":3041.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY ","code_information":[{"code":"113","type":"RC"},{"code":"770","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Myeloperoxidase (MPO) ","code_information":[{"code":"303","type":"RC"},{"code":"83876","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":50.860,"maximum":143.430,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":143.430,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":143.430,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":50.860,"methodology":"fee schedule"}]}]},{"description":"Removal of lung, pneumonectomy; with resection of segment of trachea followed by broncho-tracheal anastomosis (sleeve pneumonectomy) ","code_information":[{"code":"32442","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3061.000,"maximum":13127.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":13127.000,"methodology":"case rate"}]}]},{"description":"Urography, infusion, drip technique and/or bolus technique; with nephrotomography ","code_information":[{"code":"402","type":"RC"},{"code":"74415","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":159.160,"maximum":405.760,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":405.760,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":405.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":159.160,"methodology":"fee schedule"}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHE ","code_information":[{"code":"137","type":"RC"},{"code":"838","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) High Cost Surgery","code_information":[{"code":"490","type":"RC"},{"code":"58571","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2369.000,"maximum":2369.000,"payers_information":[{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":2369.000,"methodology":"case rate"}]}]},{"description":"INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"140","type":"RC"},{"code":"387","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"ACTH stimulation panel; for adrenal insufficiency This panel must include the following: Cortisol (82533 x 2) ","code_information":[{"code":"314","type":"RC"},{"code":"80400","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.950,"maximum":113.560,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":113.560,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":113.560,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":27.950,"methodology":"fee schedule"}]}]},{"description":"CONCUSSION WITH MCC 4 Day Stay","code_information":[{"code":"088","type":"MS-DRG"},{"code":"144","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"351","type":"RC"},{"code":"74170","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.950,"maximum":401.740,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":401.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":183.950,"methodology":"fee schedule"}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"167","type":"RC"},{"code":"195","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"MAJOR ESOPHAGEAL DISORDERS WITH CC 4 Day Stay","code_information":[{"code":"152","type":"RC"},{"code":"369","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation ","code_information":[{"code":"25607","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":9851.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7367.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8349.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SKIN DEBRIDEMENT WITH MCC 3 Day Stay","code_information":[{"code":"122","type":"RC"},{"code":"570","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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"}]}]},{"description":"HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC 2 Day Stay","code_information":[{"code":"126","type":"RC"},{"code":"421","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"APPENDIX PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"110","type":"RC"},{"code":"399","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"DENTAL AND ORAL DISEASES WITH MCC 4 Day Stay","code_information":[{"code":"127","type":"RC"},{"code":"157","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC 3 Day Stay","code_information":[{"code":"131","type":"RC"},{"code":"862","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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"}]}]},{"description":"Replacement, aortic valve, open, with cardiopulmonary bypass; with prosthetic valve other than homograft or stentless valve ","code_information":[{"code":"33405","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint, includes internal fixation, when performed, each ","code_information":[{"code":"26746","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":678.000,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":1120.920,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1197.100,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1197.100,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1197.100,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1197.100,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":1077.390,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":678.000,"methodology":"case rate"}]}]},{"description":"EXTRACRANIAL PROCEDURES WITH CC ","code_information":[{"code":"038","type":"MS-DRG"},{"code":"115","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALL ","code_information":[{"code":"129","type":"RC"},{"code":"447","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC ","code_information":[{"code":"025","type":"MS-DRG"},{"code":"122","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC ","code_information":[{"code":"132","type":"RC"},{"code":"872","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Canthotomy (separate procedure) ","code_information":[{"code":"481","type":"RC"},{"code":"67715","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":749.300,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3657.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":4567.070,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":4567.070,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":4838.000,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5089.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":749.300,"methodology":"fee schedule"}]}]},{"description":"Thawing of cryopreserved; oocytes, each aliquot ","code_information":[{"code":"307","type":"RC"},{"code":"89356","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":149.160,"maximum":149.160,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":149.160,"methodology":"fee schedule"}]}]},{"description":"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH M ","code_information":[{"code":"145","type":"RC"},{"code":"640","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"VIRAL ILLNESS WITHOUT MCC ","code_information":[{"code":"124","type":"RC"},{"code":"866","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC 3 Day Stay","code_information":[{"code":"117","type":"RC"},{"code":"749","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Sternal debridement ","code_information":[{"code":"21627","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15581.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5269.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6431.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6431.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6827.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7223.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"}]}]},{"description":"Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique ","code_information":[{"code":"360","type":"RC"},{"code":"G6019","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC ","code_information":[{"code":"122","type":"RC"},{"code":"831","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC ","code_information":[{"code":"137","type":"RC"},{"code":"360","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":2958.000,"payers_information":[{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITH MCC ","code_information":[{"code":"080","type":"MS-DRG"},{"code":"101","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCE 4 Day Stay","code_information":[{"code":"111","type":"RC"},{"code":"829","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC 3 Day Stay","code_information":[{"code":"127","type":"RC"},{"code":"319","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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12.6 cm to 20.0 cm ","code_information":[{"code":"12035","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":153.530,"maximum":5841.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":180.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":603.870,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":754.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":754.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":798.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":840.310,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2527.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2650.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":153.530,"methodology":"fee schedule"}]}]},{"description":"CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC ","code_information":[{"code":"149","type":"RC"},{"code":"259","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Surgraft tl, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"636","type":"RC"},{"code":"Q4263","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"Removal of embedded foreign body, vestibule of mouth; complicated ","code_information":[{"code":"40805","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":161.610,"maximum":7227.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1170.310,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1427.970,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1427.970,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1516.480,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1604.990,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2251.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":161.610,"methodology":"fee schedule"}]}]},{"description":"SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC ","code_information":[{"code":"053","type":"MS-DRG"},{"code":"154","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic ","code_information":[{"code":"0220T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":15581.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10205.020,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12453.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12453.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13221.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13988.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"}]}]},{"description":"Burr hole(s); with aspiration of hematoma or cyst, intracerebral ","code_information":[{"code":"362","type":"RC"},{"code":"61156","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC 4 Day Stay","code_information":[{"code":"137","type":"RC"},{"code":"280","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"PROSTATECTOMY WITH MCC 3 Day Stay","code_information":[{"code":"149","type":"RC"},{"code":"665","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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"}]}]},{"description":"SYNCOPE AND COLLAPSE ","code_information":[{"code":"114","type":"RC"},{"code":"312","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Teletherapy isodose plan; complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s) ","code_information":[{"code":"320","type":"RC"},{"code":"77307","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":887.560,"maximum":887.560,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":887.560,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":887.560,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC ","code_information":[{"code":"134","type":"RC"},{"code":"177","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"TESTES PROCEDURES WITH CC/MCC Pediatric","code_information":[{"code":"711","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":35493.270,"maximum":45637.560,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":35493.270,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":39914.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":39914.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":42776.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":45637.560,"methodology":"fee schedule"}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC ","code_information":[{"code":"064","type":"MS-DRG"},{"code":"147","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Repositioning of previously implanted cardiac venous system (left ventricular) electrode (including removal, insertion and/or replacement of existing generator) ","code_information":[{"code":"33226","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1199.900,"maximum":15410.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5237.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6540.220,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6540.220,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6928.200,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7288.470,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1199.900,"methodology":"fee schedule"}]}]},{"description":"BONE DISEASES AND ARTHROPATHIES WITHOUT MCC 2 Day Stay","code_information":[{"code":"133","type":"RC"},{"code":"554","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC ","code_information":[{"code":"141","type":"RC"},{"code":"424","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Repair of postinfarction ventricular septal defect, with or without myocardial resection ","code_information":[{"code":"33545","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":41663.310,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":30394.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":37091.290,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":37091.290,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":39377.300,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":41663.310,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"149","type":"RC"},{"code":"257","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"TRANSURETHRAL PROSTATECTOMY WITH CC/MCC 2 Day Stay","code_information":[{"code":"138","type":"RC"},{"code":"713","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Venography, renal, bilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"342","type":"RC"},{"code":"75833","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":149.950,"maximum":498.980,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":498.980,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":498.980,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":149.950,"methodology":"fee schedule"}]}]},{"description":"Unlisted laparoscopy procedure, intestine (except rectum) ","code_information":[{"code":"44238","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":12712.660,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9135.710,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11407.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11407.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12084.270,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12712.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"}]}]},{"description":"AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC 4 Day Stay","code_information":[{"code":"156","type":"RC"},{"code":"268","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"MOD SED DIFF PHYS/QHP ADD ON ","code_information":[{"code":"360","type":"RC"},{"code":"99150","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"RENAL FAILURE WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"159","type":"RC"},{"code":"684","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC 4 Day Stay","code_information":[{"code":"156","type":"RC"},{"code":"736","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Intersex surgery; male to female ","code_information":[{"code":"490","type":"RC"},{"code":"55970","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":11234.150,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8073.210,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":10080.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":10080.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":10678.850,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11234.150,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"}]}]},{"description":"Coronary endarterectomy, open, any method, of left anterior descending, circumflex, or right coronary artery performed in conjunction with coronary artery bypass graft procedure, each vessel (List sep ","code_information":[{"code":"33572","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC ","code_information":[{"code":"144","type":"RC"},{"code":"918","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiologi ","code_information":[{"code":"50432","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":646.270,"maximum":3589.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3589.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2768.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2768.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":2630.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":3257.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1904.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":672.380,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":718.080,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":718.080,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":718.080,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":718.080,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":646.270,"methodology":"fee schedule"}]}]},{"description":"NEUROLOGICAL EYE DISORDERS 4 Day Stay","code_information":[{"code":"123","type":"MS-DRG"},{"code":"153","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"Days 5+. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1964.000,"methodology":"case rate","additional_payer_notes":"Days 5+. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":2433.000,"methodology":"case rate","additional_payer_notes":"Days 5+. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1422.000,"methodology":"case rate","additional_payer_notes":"Days 5+. "}]}]},{"description":"STROKE; M > 44.45 & M < 51.05 & C < 18.5 ","code_information":[{"code":"128","type":"RC"},{"code":"B0103","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":27233.270,"maximum":29684.270,"payers_information":[{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":27233.270,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":27233.270,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":29684.270,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":28594.930,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":27777.940,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":27777.940,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":27777.940,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":27777.940,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":27777.940,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":28594.930,"methodology":"fee schedule"}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC 2 Day Stay","code_information":[{"code":"139","type":"RC"},{"code":"757","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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"}]}]},{"description":"Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe only ","code_information":[{"code":"324","type":"RC"},{"code":"93313","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.250,"maximum":11.250,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":11.250,"methodology":"fee schedule"}]}]},{"description":"Bridge base metal cast ","code_information":[{"code":"D6211","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5110.700,"maximum":5110.700,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5110.700,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5110.700,"methodology":"fee schedule"}]}]},{"description":"Phototherapeutic keratectomy (ptk) ","code_information":[{"code":"499","type":"RC"},{"code":"S0812","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":13988.660,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10205.020,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12453.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12453.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13221.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13988.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Gastric restrictive procedure, open; revision of subcutaneous port component only ","code_information":[{"code":"369","type":"RC"},{"code":"43886","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1564.090,"maximum":15410.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1840.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5627.080,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7026.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7026.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7443.230,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7830.270,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1564.090,"methodology":"fee schedule"}]}]},{"description":"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC ","code_information":[{"code":"147","type":"RC"},{"code":"406","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Intraoperative colonic lavage (List separately in addition to code for primary procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"44701","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1672.000,"maximum":5841.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"Bypass graft, with vein; axillary-brachial ","code_information":[{"code":"35522","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":16308.150,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11897.140,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14518.540,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14518.540,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":15413.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16308.150,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"036","type":"MS-DRG"},{"code":"110","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Treatment of missed abortion, completed surgically; first trimester ","code_information":[{"code":"59820","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4721.410,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":5895.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":5895.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6245.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6570.000,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7367.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8349.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1141.200,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, cervical spine; without contrast material ","code_information":[{"code":"72125","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":109.020,"maximum":109.020,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":109.020,"methodology":"fee schedule"}]}]},{"description":"BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC 2 Day Stay","code_information":[{"code":"135","type":"RC"},{"code":"519","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Alcohol (ethanol); breath ","code_information":[{"code":"734870","type":"CDM"},{"code":"82075","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.950,"maximum":109.590,"gross_charge":238.75,"discounted_cash":238.75,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":30.250,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":27.220,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":30.000,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":31.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":68.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":83.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":83.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":89.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":30.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":30.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":30.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":94.200,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":81.900,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":93.010,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":109.590,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":30.000,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":30.000,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":30.000,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":30.000,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":30.000,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":59.400,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":25.960,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":60.000,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":72.900,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":30.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":30.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":30.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":30.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":30.000,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":30.000,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":32.700,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":27.720,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":72.900,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":27.720,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":27.720,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":27.720,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":63.000,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":70.500,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":31.500,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":31.500,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":31.800,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":31.800,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":31.800,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":31.800,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":31.800,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":31.500,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":46.500,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":31.500,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":31.500,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":31.500,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":24.950,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":32.470,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":30.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":30.600,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":36.000,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":29.400,"methodology":"fee schedule"}]}]},{"description":"Biopsy, vertebral body, open; lumbar or cervical ","code_information":[{"code":"20251","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomography, upper extremity; without contrast material ","code_information":[{"code":"73200","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":109.020,"maximum":109.020,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":109.020,"methodology":"fee schedule"}]}]},{"description":"MAJOR CHEST TRAUMA WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"153","type":"RC"},{"code":"185","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALL 2 Day Stay","code_information":[{"code":"135","type":"RC"},{"code":"447","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Blood count; hemoglobin (Hgb) ","code_information":[{"code":"301","type":"RC"},{"code":"85018","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2.030,"maximum":8.260,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":8.260,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":8.260,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2.370,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2.030,"methodology":"fee schedule"}]}]},{"description":"ATHERECTOMY, OPEN ","code_information":[{"code":"35483","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC 3 Day Stay","code_information":[{"code":"134","type":"RC"},{"code":"823","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Suture facial nerve, intratemporal, with or without graft or decompression; including medial to geniculate ganglion ","code_information":[{"code":"499","type":"RC"},{"code":"69745","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2096.960,"maximum":12756.890,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9167.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11447.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11447.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12126.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12756.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7367.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8349.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2096.960,"methodology":"fee schedule"}]}]},{"description":"POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC 4 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"857","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Bypass graft, with other than vein, transcervical retropharyngeal carotid-carotid, performed in conjunction with endovascular repair of descending thoracic aorta, by neck incision ","code_information":[{"code":"33891","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":12922.400,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9427.160,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11504.330,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11504.330,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12213.370,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12922.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS 4 Day Stay","code_information":[{"code":"130","type":"RC"},{"code":"208","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s) ","code_information":[{"code":"731","type":"RC"},{"code":"73719","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":280.140,"maximum":280.140,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":280.140,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY NEOPLASMS WITH CC 3 Day Stay","code_information":[{"code":"167","type":"RC"},{"code":"181","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC* ","code_information":[{"code":"148","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5202.300,"maximum":5202.300,"payers_information":[{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":5202.300,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with vein; subclavian-subclavian ","code_information":[{"code":"35511","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":14783.170,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10784.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":13160.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":13160.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13972.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14783.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC ","code_information":[{"code":"138","type":"RC"},{"code":"565","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"133","type":"RC"},{"code":"630","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WIT ","code_information":[{"code":"148","type":"RC"},{"code":"562","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Clotting; factor VIII, VW factor antigen ","code_information":[{"code":"85246","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":19.660,"maximum":22.940,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":22.940,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":19.660,"methodology":"fee schedule"}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC ","code_information":[{"code":"160","type":"RC"},{"code":"840","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC 2 Day Stay","code_information":[{"code":"002","type":"MS-DRG"},{"code":"124","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC ","code_information":[{"code":"169","type":"RC"},{"code":"179","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Polygon3 membrane, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"636","type":"RC"},{"code":"Q4400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"VALVOTOMY, PULMONARY VALVE, CLOSED HEART; TRANSVENTRICULAR ","code_information":[{"code":"33470","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspirationºs»/biopsyºies ","code_information":[{"code":"31653","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":13370.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":9999.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":11331.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":13370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC ","code_information":[{"code":"115","type":"RC"},{"code":"481","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure) ","code_information":[{"code":"22842","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1672.000,"maximum":28161.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":28161.000,"methodology":"case rate"}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITH MCC 4 Day Stay","code_information":[{"code":"152","type":"RC"},{"code":"444","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"ARTHRODESIS, PRE-SACRAL INTERBODY TECHNIQUE, DISC SPACE PREPARATION, DISCECTOMY, WITHOUT INSTRUMENTATION, WITH IMAGE GUIDANCE, INCLUDES BONE GRAFT WHEN PERFORMED; L5-S1 INTERSPACE ","code_information":[{"code":"0195T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZA ","code_information":[{"code":"136","type":"RC"},{"code":"217","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 2 or 3 views ","code_information":[{"code":"615","type":"RC"},{"code":"72082","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":71.910,"maximum":71.910,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":71.910,"methodology":"fee schedule"}]}]},{"description":"MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"128","type":"RC"},{"code":"370","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC 4 Day Stay","code_information":[{"code":"132","type":"RC"},{"code":"360","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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"}]}]},{"description":"Arthroscopy, shoulder, surgical; synovectomy, partial ","code_information":[{"code":"29820","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":9124.000,"maximum":9124.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9124.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INTRAOCULAR PROCEDURES WITH CC/MCC 4 Day Stay","code_information":[{"code":"116","type":"MS-DRG"},{"code":"167","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Removal of drug-delivery device(s), intramedullary (List separately in addition to code for primary procedure) ","code_information":[{"code":"20703","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1672.000,"maximum":5055.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"151","type":"RC"},{"code":"989","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC 4 Day Stay","code_information":[{"code":"134","type":"RC"},{"code":"351","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Application, cast; shoulder to hand (long arm) ","code_information":[{"code":"29065","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":52.880,"maximum":5841.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":358.610,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":437.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":437.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":464.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":491.800,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":52.880,"methodology":"fee schedule"}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC ","code_information":[{"code":"095","type":"MS-DRG"},{"code":"143","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"WOUND DEBRIDEMENTS FOR INJURIES WITH CC 4 Day Stay","code_information":[{"code":"139","type":"RC"},{"code":"902","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Magnetoencephalography (MEG), recording and analysis; for spontaneous brain magnetic activity (eg, epileptic cerebral cortex localization) ","code_information":[{"code":"483","type":"RC"},{"code":"95965","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":964.060,"maximum":964.060,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":964.060,"methodology":"fee schedule"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY 4 Day Stay","code_information":[{"code":"149","type":"RC"},{"code":"895","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC 2 Day Stay","code_information":[{"code":"121","type":"RC"},{"code":"418","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC 3 Day Stay","code_information":[{"code":"131","type":"RC"},{"code":"555","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITH MCC ","code_information":[{"code":"080","type":"MS-DRG"},{"code":"160","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, each increment of 12-26 hours; with intermittent monitoring and maintenance ","code_information":[{"code":"95715","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2063.840,"maximum":2831.110,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2063.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":2520.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":2520.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":2675.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2831.110,"methodology":"fee schedule"}]}]},{"description":"MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND CO ","code_information":[{"code":"810","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3531.310,"maximum":3531.310,"payers_information":[{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":3531.310,"methodology":"fee schedule"}]}]},{"description":"Ablation of benign prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU), including ultrasound guidance ","code_information":[{"code":"0950T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":12635.000,"maximum":24320.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":17477.110,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":21823.270,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":21823.270,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":23117.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":24320.000,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"}]}]},{"description":"Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus ","code_information":[{"code":"31259","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1749.190,"maximum":15410.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10282.280,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12839.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12839.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13600.900,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14308.150,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":9999.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":11331.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":13370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1749.190,"methodology":"fee schedule"}]}]},{"description":"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC ","code_information":[{"code":"121","type":"RC"},{"code":"604","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"CORONARY BYPASS WITH PTCA WITH MCC 2 Day Stay","code_information":[{"code":"120","type":"RC"},{"code":"231","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC 3 Day Stay","code_information":[{"code":"155","type":"RC"},{"code":"241","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Repair, extensor tendon, finger, primary or secondary; without free graft, each tendon ","code_information":[{"code":"26418","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":636.360,"maximum":8444.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2561.690,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3198.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3198.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3388.480,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3564.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":636.360,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or first gestation ","code_information":[{"code":"74712","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":238.190,"maximum":238.190,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":238.190,"methodology":"fee schedule"}]}]},{"description":"Radial keratotomy ","code_information":[{"code":"361","type":"RC"},{"code":"65771","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":6290.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7676.470,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7676.470,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":8149.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8622.700,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"}]}]},{"description":"Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); 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"}]}]},{"description":"AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC 2 Day Stay","code_information":[{"code":"144","type":"RC"},{"code":"475","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Cyclic citrullinated peptide (CCP), antibody ","code_information":[{"code":"86200","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":11.100,"maximum":12.950,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.950,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":11.100,"methodology":"fee schedule"}]}]},{"description":"Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, (ie, bidirectional Doppler waveform or volume plethysmography recording and analysis at res ","code_information":[{"code":"925","type":"RC"},{"code":"93924","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":163.600,"maximum":163.600,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":163.600,"methodology":"fee schedule"}]}]},{"description":"Endodontic endosseous implan ","code_information":[{"code":"750","type":"RC"},{"code":"D3460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of ","code_information":[{"code":"33951","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12018.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4211.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":5139.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":5139.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":5456.540,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5773.310,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"SPINAL PROCEDURES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"030","type":"MS-DRG"},{"code":"100","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"EXCISION OF CHEST WALL TUMOR INVOLVING RIBS, WITH PLASTIC RECONSTRUCTION; WITH MEDIASTINAL LYMPHADENECTOMY ","code_information":[{"code":"19272","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist; with tendon(s) transfer ","code_information":[{"code":"25316","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2573.700,"maximum":15732.530,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11305.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14954.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15732.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2573.700,"methodology":"fee schedule"}]}]},{"description":"OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC 2 Day Stay","code_information":[{"code":"157","type":"RC"},{"code":"749","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC 3 Day Stay","code_information":[{"code":"155","type":"RC"},{"code":"862","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level ","code_information":[{"code":"480","type":"RC"},{"code":"64490","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2251.000,"maximum":2251.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2251.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCE 4 Day Stay","code_information":[{"code":"132","type":"RC"},{"code":"830","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC 3 Day Stay","code_information":[{"code":"127","type":"RC"},{"code":"286","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC ","code_information":[{"code":"128","type":"RC"},{"code":"269","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Thoracoplasty, Schede type or extrapleural (all stages); with closure of bronchopleural fistula ","code_information":[{"code":"32906","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3061.000,"maximum":13127.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":13127.000,"methodology":"case rate"}]}]},{"description":"Drug metabolism or processing (mult conditions), whole blood or buccal specimen, DNA analysis, 25 gene report, with variant analysis and reported phenotypes ","code_information":[{"code":"0348U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":727.420,"maximum":1803.720,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":748.580,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":742.270,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":779.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1032.580,"methodology":"fee 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4521.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":708.150,"methodology":"fee schedule"}]}]},{"description":"DIABETES WITHOUT CC/MCC ","code_information":[{"code":"101","type":"RC"},{"code":"639","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per 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"}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITH MCC 4 Day Stay","code_information":[{"code":"157","type":"RC"},{"code":"974","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC ","code_information":[{"code":"143","type":"RC"},{"code":"727","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC ","code_information":[{"code":"142","type":"RC"},{"code":"255","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"PENIS PROCEDURES WITH CC/MCC 2 Day Stay","code_information":[{"code":"141","type":"RC"},{"code":"709","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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"}]}]},{"description":"Computed tomography, lower extremity; with contrast material(s) ","code_information":[{"code":"352","type":"RC"},{"code":"73701","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":176.540,"maximum":401.740,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":401.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":176.540,"methodology":"fee schedule"}]}]},{"description":"CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC ","code_information":[{"code":"144","type":"RC"},{"code":"234","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. 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"}]}]},{"description":"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC ","code_information":[{"code":"131","type":"RC"},{"code":"147","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC 4 Day Stay","code_information":[{"code":"164","type":"RC"},{"code":"872","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC 3 Day Stay","code_information":[{"code":"157","type":"RC"},{"code":"255","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"141","type":"RC"},{"code":"416","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Esophagoscopy, flexible, transoral, with initial transendoscopic mechanical dilation (eg, nondrug-coated balloon) followed by therapeutic drug delivery by drug-coated balloon catheter for esophageal s ","code_information":[{"code":"0884T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6896.530,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":6896.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":8611.550,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":8611.550,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":9122.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9596.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"}]}]},{"description":"RED BLOOD CELL DISORDERS WITHOUT MCC ","code_information":[{"code":"159","type":"RC"},{"code":"812","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Fragmentation in Descending Colon, External Approach ","code_information":[{"code":"0DFMXZZ","type":"ICD"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":2905.000,"maximum":2905.000,"payers_information":[{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":2905.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":2905.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":2905.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":2905.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":2905.000,"methodology":"case rate"}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOT ","code_information":[{"code":"117","type":"RC"},{"code":"837","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"OSTEOMYELITIS WITH CC ","code_information":[{"code":"130","type":"RC"},{"code":"540","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"SEPTIC ARTHRITIS WITH CC 2 Day Stay","code_information":[{"code":"110","type":"RC"},{"code":"549","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331) ","code_information":[{"code":"24301","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15732.530,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11305.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14954.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15732.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case 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"}]}]},{"description":"MALIGNANT BREAST DISORDERS WITH CC 2 Day Stay","code_information":[{"code":"118","type":"RC"},{"code":"598","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC 4 Day Stay","code_information":[{"code":"148","type":"RC"},{"code":"841","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure); with excision of adjacent retroperitoneal tumor ","code_information":[{"code":"361","type":"RC"},{"code":"60545","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":16485.300,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":12026.370,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14676.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14676.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":15580.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16485.300,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Orbitocranial zygomatic approach to middle cranial fossa (cavernous sinus and carotid artery, clivus, basilar artery or petrous apex) including osteotomy of zygoma, craniotomy, extra- or intradural el ","code_information":[{"code":"61592","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3061.000,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Triiodothyronine T3; total (TT-3) ","code_information":[{"code":"312","type":"RC"},{"code":"84480","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.150,"maximum":49.380,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":49.380,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":49.380,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":12.150,"methodology":"fee schedule"}]}]},{"description":"TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC 4 Day Stay","code_information":[{"code":"083","type":"MS-DRG"},{"code":"157","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Dural graft, spinal ","code_information":[{"code":"361","type":"RC"},{"code":"63710","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":14736.590,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10750.650,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":13119.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":13119.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13928.010,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14736.590,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH MCC ","code_information":[{"code":"0D1B8ZB","type":"ICD"},{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2950.000,"maximum":2950.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2950.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"033","type":"MS-DRG"},{"code":"128","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Abortion maternal indic>=25w ","code_information":[{"code":"369","type":"RC"},{"code":"S2262","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WIT 4 Day Stay","code_information":[{"code":"138","type":"RC"},{"code":"495","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Cerclage of cervix, during pregnancy; vaginal ","code_information":[{"code":"361","type":"RC"},{"code":"59320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12635.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1342.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4721.410,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":5895.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":5895.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6245.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6570.000,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1141.200,"methodology":"fee schedule"}]}]},{"description":"OTHER CEREBROVASCULAR DISORDERS WITH MCC 4 Day Stay","code_information":[{"code":"070","type":"MS-DRG"},{"code":"128","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC ","code_information":[{"code":"126","type":"RC"},{"code":"261","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"TRANSURETHRAL PROSTATECTOMY WITH CC/MCC ","code_information":[{"code":"147","type":"RC"},{"code":"713","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"LIVER TRANSPLANT WITHOUT MCC 2 Day Stay","code_information":[{"code":"006","type":"MS-DRG"},{"code":"121","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"NERVOUS SYSTEM NEOPLASMS WITH MCC 4 Day Stay","code_information":[{"code":"054","type":"MS-DRG"},{"code":"133","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"INTRAOCULAR PROCEDURES WITH CC/MCC ","code_information":[{"code":"116","type":"MS-DRG"},{"code":"116","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"ATXN2 (ataxin 2) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"314","type":"RC"},{"code":"81179","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":117.380,"maximum":117.380,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":117.380,"methodology":"fee schedule"}]}]},{"description":"Resection of lip, more than one-fourth, without reconstruction ","code_information":[{"code":"40530","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4950.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6181.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6181.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6548.230,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6888.730,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":951.370,"methodology":"fee schedule"}]}]},{"description":"SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS 3 Day Stay","code_information":[{"code":"151","type":"RC"},{"code":"870","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Obliteration of carotid aneurysm, arteriovenous malformation, or carotid-cavernous fistula by dissection within cavernous sinus ","code_information":[{"code":"481","type":"RC"},{"code":"61613","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":45226.210,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":32993.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":40263.210,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":40263.210,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":42744.710,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":45226.210,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC 4 Day Stay","code_information":[{"code":"138","type":"RC"},{"code":"405","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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PROCEDURES WITH CC 3 Day Stay","code_information":[{"code":"134","type":"RC"},{"code":"144","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"DISORDERS OF IMPULSE CONTROL & DEVELOPMENT ","code_information":[{"code":"7584","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7472.450,"maximum":8706.740,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":8706.740,"methodology":"fee schedule"},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":7774.370,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":7925.330,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":7925.330,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":7925.330,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":7925.330,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":7884.130,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":7884.130,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":7884.130,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":7884.130,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":7884.130,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":7472.450,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":7698.890,"methodology":"fee schedule"}]}]},{"description":"KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC ","code_information":[{"code":"122","type":"RC"},{"code":"486","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Endoscopic retrograde cholangiopancreatography (ERCP); with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, inclu ","code_information":[{"code":"43276","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3041.000,"maximum":3041.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus; ","code_information":[{"code":"28104","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case 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"}]}]},{"description":"Thoracoplasty, Schede type or extrapleural (all stages); with closure of bronchopleural fistula ","code_information":[{"code":"32906","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":22193.390,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":16190.540,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":19757.950,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":19757.950,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":20975.670,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":22193.390,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Removal fb skin/areolar tiss ","code_information":[{"code":"481","type":"RC"},{"code":"D7530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER O.R. 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PROCEDURES FOR OBESITY WITH MCC 2 Day Stay","code_information":[{"code":"137","type":"RC"},{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"087","type":"MS-DRG"},{"code":"169","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC A ","code_information":[{"code":"063","type":"MS-DRG"},{"code":"112","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"MAJOR ESOPHAGEAL DISORDERS WITH MCC ","code_information":[{"code":"138","type":"RC"},{"code":"368","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"138","type":"RC"},{"code":"387","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Esophagoscopy, rigid, transoral; diagnostic, including collection of specimen(s) by brushing or washing when performed (separate procedure) ","code_information":[{"code":"43191","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":559.320,"maximum":2678.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":2678.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1964.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":2433.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1422.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":581.920,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":621.470,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":621.470,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":621.470,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":621.470,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":559.320,"methodology":"fee schedule"}]}]},{"description":"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC 3 Day Stay","code_information":[{"code":"101","type":"RC"},{"code":"863","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC ","code_information":[{"code":"10D00Z1","type":"ICD"},{"code":"110","type":"RC"},{"code":"788","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7586.000,"maximum":14288.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":14288.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":11025.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":11025.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":10475.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":12969.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":7586.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"FOOT PROCEDURES WITH MCC ","code_information":[{"code":"149","type":"RC"},{"code":"503","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Excimer laser treatment for psoriasis; total area less than 250 sq cm ","code_information":[{"code":"96920","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1422.000,"maximum":2678.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":2678.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1964.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":2433.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1422.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"TRAUMATIC INJURY WITHOUT MCC ","code_information":[{"code":"116","type":"RC"},{"code":"914","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC ","code_information":[{"code":"155","type":"RC"},{"code":"480","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC ","code_information":[{"code":"149","type":"RC"},{"code":"521","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"MEDICAL BACK PROBLEMS WITH MCC ","code_information":[{"code":"153","type":"RC"},{"code":"551","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (List separately in addition to code for primary procedure) ","code_information":[{"code":"0054T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1672.000,"maximum":2940.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"Glycine receptor alpha1 IgG, serum or cerebrospinal fluid, live cell-binding assay, qualitative ","code_information":[{"code":"0431U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":36.570,"maximum":36.570,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":36.570,"methodology":"fee schedule"}]}]},{"description":"CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC 3 Day Stay","code_information":[{"code":"155","type":"RC"},{"code":"233","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Destruction of neurofibroma, extensive (cutaneous, dermal extending into subcutaneous); trunk and extremities, extensive, greater than 100 neurofibromas ","code_information":[{"code":"0420T","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2946.000,"maximum":5055.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bypass graft, with other than vein; aortoceliac, aortomesenteric, aortorenal ","code_information":[{"code":"35631","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":25052.100,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":18276.030,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":22302.950,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":22302.950,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":23677.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25052.100,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC ","code_information":[{"code":"136","type":"RC"},{"code":"576","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC ","code_information":[{"code":"164","type":"RC"},{"code":"958","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"KIDNEY TRANSPLANT ","code_information":[{"code":"114","type":"RC"},{"code":"652","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"HIV WITH OR WITHOUT OTHER RELATED CONDITION 2 Day Stay","code_information":[{"code":"146","type":"RC"},{"code":"977","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES 4 Day Stay","code_information":[{"code":"133","type":"RC"},{"code":"843","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISOR ","code_information":[{"code":"129","type":"RC"},{"code":"622","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Antibody; mucormycosis ","code_information":[{"code":"306","type":"RC"},{"code":"86732","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.850,"maximum":45.910,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":45.910,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":45.910,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":12.850,"methodology":"fee schedule"}]}]},{"description":"Rheumatoid factor; quantitative ","code_information":[{"code":"864300","type":"CDM"},{"code":"86431","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.710,"maximum":20.740,"gross_charge":863.20,"discounted_cash":863.20,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","median_amount":136.180,"10th_percentile":128.480,"90th_percentile":305.570,"count":"1 through 10","methodology":"percent of total billed charges","additional_payer_notes":" Between 1-10 instances of this service in the last 15 months prior to posting and may not be statistically significant. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":5.720,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":5.140,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":5.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":12.980,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":15.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":15.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":16.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17.800,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":15.500,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":17.600,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":20.740,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":11.230,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":4.900,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":11.340,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":17.010,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":6.180,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":5.240,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":13.780,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":5.240,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":5.240,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":5.240,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":11.910,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":13.320,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":5.950,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":5.950,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":6.010,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":6.010,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":6.010,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":6.010,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":6.010,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":5.950,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":8.790,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":5.950,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":5.950,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":5.950,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":4.710,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":6.140,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":6.800,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":5.560,"methodology":"fee schedule"}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed ","code_information":[{"code":"367","type":"RC"},{"code":"64454","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC 3 Day Stay","code_information":[{"code":"146","type":"RC"},{"code":"371","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"ATHEROSCLEROSIS WITH MCC 2 Day Stay","code_information":[{"code":"100","type":"RC"},{"code":"302","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Colonoscopy through stoma; with directed submucosal injection(s), any substance ","code_information":[{"code":"362","type":"RC"},{"code":"44404","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":8444.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC 2 Day Stay","code_information":[{"code":"082","type":"MS-DRG"},{"code":"129","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Intestine imaging (eg, ectopic gastric mucosa, Meckel's localization, volvulus) ","code_information":[{"code":"610","type":"RC"},{"code":"78290","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":331.280,"maximum":331.280,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":331.280,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance imaging guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation ","code_information":[{"code":"610","type":"RC"},{"code":"77021","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1641.000,"maximum":3090.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3090.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2385.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2385.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":2265.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":2807.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1641.000,"methodology":"per diem"}]}]},{"description":"Repair, secondary, disrupted ligament, ankle, collateral (eg, Watson-Jones procedure) ","code_information":[{"code":"27698","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15732.530,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":3941.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11305.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14954.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15732.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":3349.860,"methodology":"fee schedule"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC 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"}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITHOUT MCC Pediatric","code_information":[{"code":"081","type":"MS-DRG"},{"code":"203","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":13043.000,"maximum":17441.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":13043.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":14780.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":17441.000,"methodology":"case rate"}]}]},{"description":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZA 4 Day Stay","code_information":[{"code":"116","type":"RC"},{"code":"216","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MC ","code_information":[{"code":"125","type":"RC"},{"code":"517","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"CELLULITIS WITHOUT MCC 3 Day Stay","code_information":[{"code":"142","type":"RC"},{"code":"603","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC 4 Day Stay","code_information":[{"code":"137","type":"RC"},{"code":"423","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC 4 Day Stay","code_information":[{"code":"130","type":"RC"},{"code":"757","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC ","code_information":[{"code":"112","type":"RC"},{"code":"650","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code f ","code_information":[{"code":"362","type":"RC"},{"code":"64634","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC 2 Day Stay","code_information":[{"code":"115","type":"RC"},{"code":"802","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"NERVOUS SYSTEM NEOPLASMS WITH MCC 4 Day Stay","code_information":[{"code":"054","type":"MS-DRG"},{"code":"116","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"FRACTURES OF HIP AND PELVIS WITHOUT MCC 2 Day Stay","code_information":[{"code":"151","type":"RC"},{"code":"536","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"111","type":"RC"},{"code":"759","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion ","code_information":[{"code":"19125","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1034.050,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5725.850,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7149.740,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7149.740,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7573.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7967.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure 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"}]}]},{"description":"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY 3 Day Stay","code_information":[{"code":"149","type":"RC"},{"code":"770","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC 3 Day Stay","code_information":[{"code":"117","type":"RC"},{"code":"371","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), ","code_information":[{"code":"34703","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WIT 4 Day Stay","code_information":[{"code":"140","type":"RC"},{"code":"496","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Methylenedioxyamphetamines (MDA, MDEA, MDMA) ","code_information":[{"code":"319","type":"RC"},{"code":"80359","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.670,"maximum":26.650,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":26.650,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":26.650,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":8.670,"methodology":"fee schedule"}]}]},{"description":"VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"033","type":"MS-DRG"},{"code":"138","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. 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"}]}]},{"description":"DIGESTIVE MALIGNANCY WITH CC 3 Day Stay","code_information":[{"code":"146","type":"RC"},{"code":"375","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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"}]}]},{"description":"Blood typing, for paternity testing, per individual; ABO, Rh and MN ","code_information":[{"code":"300","type":"RC"},{"code":"86910","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.520,"maximum":71.430,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":71.430,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":71.430,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":26.520,"methodology":"fee schedule"}]}]},{"description":"Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation (eg, maturation index, karyopyknotic index, estrogenic index) (List separately in addition to codeºs» for other technical and ","code_information":[{"code":"314","type":"RC"},{"code":"88155","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.560,"maximum":41.310,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":41.310,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":41.310,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14.650,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":12.560,"methodology":"fee schedule"}]}]},{"description":"OTHER DISORDERS OF NERVOUS SYSTEM WITH CC 2 Day Stay","code_information":[{"code":"092","type":"MS-DRG"},{"code":"140","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint ","code_information":[{"code":"64633","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":708.150,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3249.570,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":4057.670,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":4057.670,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":4298.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4521.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":708.150,"methodology":"fee schedule"}]}]},{"description":"Injection, levofloxacin, 250 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J1956","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3.560,"maximum":3.560,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3.560,"methodology":"fee schedule"}]}]},{"description":"MAJOR SKIN DISORDERS WITH MCC 2 Day Stay","code_information":[{"code":"121","type":"RC"},{"code":"595","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC ","code_information":[{"code":"119","type":"RC"},{"code":"481","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC ","code_information":[{"code":"150","type":"RC"},{"code":"857","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"013","type":"MS-DRG"},{"code":"121","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC ","code_information":[{"code":"136","type":"RC"},{"code":"488","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC ","code_information":[{"code":"150","type":"RC"},{"code":"802","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC 4 Day Stay","code_information":[{"code":"133","type":"RC"},{"code":"314","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC ","code_information":[{"code":"125","type":"RC"},{"code":"308","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"134","type":"RC"},{"code":"965","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Bypass graft, with vein; tibial-tibial, peroneal-tibial, or tibial/peroneal trunk-tibial ","code_information":[{"code":"35570","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":20393.310,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":14877.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":18155.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":18155.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":19274.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20393.310,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC 3 Day Stay","code_information":[{"code":"119","type":"RC"},{"code":"857","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT 4 Day Stay","code_information":[{"code":"005","type":"MS-DRG"},{"code":"169","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"SKIN DEBRIDEMENT WITHOUT CC/MCC ","code_information":[{"code":"158","type":"RC"},{"code":"572","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"MAJOR SKIN DISORDERS WITHOUT MCC ","code_information":[{"code":"149","type":"RC"},{"code":"596","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC ","code_information":[{"code":"142","type":"RC"},{"code":"823","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use ","code_information":[{"code":"90653","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":74.660,"maximum":745.150,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_percentage":8.07,"standard_charge_algorithm":"Reimbursement will be 8.07% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":74.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":91.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":91.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":96.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":102.500,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":160.210,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":182.400,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":215.260,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_percentage":15.84,"standard_charge_algorithm":"Reimbursement will be 15.84% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_percentage":16.00,"standard_charge_algorithm":"Reimbursement will be 16% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":745.150,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":745.150,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_percentage":8.72,"standard_charge_algorithm":"Reimbursement will be 8.72% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":19.44,"standard_charge_algorithm":"Reimbursement will be 19.44% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_percentage":16.80,"standard_charge_algorithm":"Reimbursement will be 16.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_percentage":8.48,"standard_charge_algorithm":"Reimbursement will be 8.48% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_percentage":8.48,"standard_charge_algorithm":"Reimbursement will be 8.48% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_percentage":8.48,"standard_charge_algorithm":"Reimbursement will be 8.48% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_percentage":8.48,"standard_charge_algorithm":"Reimbursement will be 8.48% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_percentage":8.48,"standard_charge_algorithm":"Reimbursement will be 8.48% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior","plan_name":"HIX","standard_charge_percentage":12.40,"standard_charge_algorithm":"Reimbursement will be 12.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":83.490,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_percentage":8.16,"standard_charge_algorithm":"Reimbursement will be 8.16% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_percentage":9.60,"standard_charge_algorithm":"Reimbursement will be 9.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_percentage":7.84,"standard_charge_algorithm":"Reimbursement will be 7.84% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH MCC ","code_information":[{"code":"0DB63ZZ","type":"ICD"},{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":26065.000,"maximum":26065.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":26065.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Hysteroscopy, surgical; with removal of leiomyomata ","code_information":[{"code":"361","type":"RC"},{"code":"58561","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1638.520,"maximum":15410.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1927.670,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8073.210,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":10080.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":10080.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":10678.850,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11234.150,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1638.520,"methodology":"fee schedule"}]}]},{"description":"INFLAMMATORY BOWEL DISEASE WITH MCC 2 Day Stay","code_information":[{"code":"137","type":"RC"},{"code":"385","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Excision of lip; V-excision with primary direct linear closure ","code_information":[{"code":"362","type":"RC"},{"code":"40520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":5487.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"117","type":"RC"},{"code":"489","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) ","code_information":[{"code":"43270","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":559.320,"maximum":4100.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":4100.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3162.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3162.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3004.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":3720.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2176.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":581.920,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":621.470,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":621.470,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":621.470,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":621.470,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":559.320,"methodology":"fee schedule"}]}]},{"description":"Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) ","code_information":[{"code":"367","type":"RC"},{"code":"45300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2946.000,"maximum":5055.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC 2 Day Stay","code_information":[{"code":"139","type":"RC"},{"code":"242","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Closed treatment of tarsal bone dislocation, other than talotarsal; requiring anesthesia ","code_information":[{"code":"28545","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":12635.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1373.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"REPAIR PARAESOPHAGEAL HERNIA ","code_information":[{"code":"39502","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare 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"}]}]},{"description":"MINOR BLADDER PROCEDURES WITH MCC ","code_information":[{"code":"153","type":"RC"},{"code":"662","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"Aquaporin-4 (neuromyelitis optica ºNMO») antibody; cell-based immunofluorescence assay (CBA), each ","code_information":[{"code":"311","type":"RC"},{"code":"86052","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.320,"maximum":10.320,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":10.320,"methodology":"fee schedule"}]}]},{"description":"Molecular cytogenetics; DNA probe, each (eg, FISH) ","code_information":[{"code":"306","type":"RC"},{"code":"88271","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.350,"maximum":74.560,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":74.560,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":74.560,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":18.350,"methodology":"fee schedule"}]}]},{"description":"Esophagoscopy, flexible, transoral; with injection sclerosis of esophageal varices ","code_information":[{"code":"369","type":"RC"},{"code":"43204","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":606.240,"maximum":5055.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":713.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2943.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3675.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3675.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3893.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4095.960,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":606.240,"methodology":"fee schedule"}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. ","code_information":[{"code":"122","type":"RC"},{"code":"827","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Antibody; Ehrlichia ","code_information":[{"code":"319","type":"RC"},{"code":"86666","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.720,"maximum":35.420,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":35.420,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":35.420,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":8.720,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC 2 Day Stay","code_information":[{"code":"152","type":"RC"},{"code":"435","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"OTHER CIRCULATORY SYSTEM O.R. 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"}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITH CC ","code_information":[{"code":"100","type":"RC"},{"code":"975","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Replacement, aortic valve; by translocation of autologous pulmonary valve with allograft replacement of pulmonary valve (Ross procedure) ","code_information":[{"code":"33413","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"EXTRACRANIAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"039","type":"MS-DRG"},{"code":"148","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT ","code_information":[{"code":"136","type":"RC"},{"code":"741","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Etonogestrel (contraceptive) implant system, including implant and supplies ","code_information":[{"code":"344","type":"RC"},{"code":"J7307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2525.210,"maximum":2525.210,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2525.210,"methodology":"fee schedule"}]}]},{"description":"MEDICAL BACK PROBLEMS WITHOUT MCC ","code_information":[{"code":"127","type":"RC"},{"code":"552","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Transduodenal sphincterotomy or sphincteroplasty, with or without transduodenal extraction of calculus (separate procedure) ","code_information":[{"code":"362","type":"RC"},{"code":"47460","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MINOR BLADDER PROCEDURES WITH MCC ","code_information":[{"code":"116","type":"RC"},{"code":"662","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC 3 Day Stay","code_information":[{"code":"117","type":"RC"},{"code":"660","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"VEIN LIGATION AND STRIPPING ","code_information":[{"code":"110","type":"RC"},{"code":"263","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Gastrectomy, partial, distal; with gastroduodenostomy ","code_information":[{"code":"43631","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":19628.560,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":14319.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":17474.570,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":17474.570,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":18551.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":19628.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Manipulation, finger joint, under anesthesia, each joint ","code_information":[{"code":"26340","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":636.360,"maximum":5841.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":748.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2561.690,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3198.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3198.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3388.480,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3564.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":636.360,"methodology":"fee schedule"}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC 2 Day Stay","code_information":[{"code":"149","type":"RC"},{"code":"737","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"133","type":"RC"},{"code":"578","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or younger, who requires intensive observation, frequent interventions, and other intensive care servic ","code_information":[{"code":"99477","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1508.710,"maximum":4728.930,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1508.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1842.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1842.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1955.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2069.590,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":4728.930,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":4728.930,"methodology":"fee schedule"}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC ","code_information":[{"code":"113","type":"RC"},{"code":"824","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"SKIN DEBRIDEMENT WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"159","type":"RC"},{"code":"572","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"APPENDIX PROCEDURES WITH MCC ","code_information":[{"code":"131","type":"RC"},{"code":"397","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Excision of lesion, esophagus, with primary repair; cervical approach ","code_information":[{"code":"43100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3061.000,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) ","code_information":[{"code":"44380","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":359.420,"maximum":5055.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1485.390,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1854.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1854.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1964.800,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2066.970,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":359.420,"methodology":"fee schedule"}]}]},{"description":"PENIS PROCEDURES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"120","type":"RC"},{"code":"710","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Inj, rykindo, 0.5 mg ","code_information":[{"code":"739","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":12.770,"maximum":31.660,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":13.140,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":13.030,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":13.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":13.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":13.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":13.030,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13.030,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13.030,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":13.030,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":13.030,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":13.030,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":25.800,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":26.060,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":13.030,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":13.030,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":13.030,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":13.030,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":13.030,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":13.030,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":14.200,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":31.660,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":27.360,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":13.680,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":13.680,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":13.810,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":13.810,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":13.810,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":13.810,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":13.810,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13.680,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":20.200,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":13.680,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":13.680,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":13.680,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13.030,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13.290,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":15.640,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":12.770,"methodology":"fee schedule"}]}]},{"description":"PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC 4 Day Stay","code_information":[{"code":"169","type":"RC"},{"code":"359","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Repair lumbar hernia ","code_information":[{"code":"369","type":"RC"},{"code":"49540","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2026.810,"maximum":15410.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":2384.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9135.710,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11407.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11407.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12084.270,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12712.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2026.810,"methodology":"fee schedule"}]}]},{"description":"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC 2 Day Stay","code_information":[{"code":"137","type":"RC"},{"code":"604","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Radiologic examination, spine, single view, specify level ","code_information":[{"code":"72020","type":"CPT"},{"code":"732","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":25.220,"maximum":25.220,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":25.220,"methodology":"fee schedule"}]}]},{"description":"CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC 4 Day Stay","code_information":[{"code":"131","type":"RC"},{"code":"307","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck) ","code_information":[{"code":"730","type":"RC"},{"code":"78814","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1509.950,"maximum":1509.950,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1509.950,"methodology":"fee schedule"}]}]},{"description":"OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC ","code_information":[{"code":"133","type":"RC"},{"code":"749","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Bone marrow imaging; limited area ","code_information":[{"code":"352","type":"RC"},{"code":"78102","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":172.460,"maximum":172.460,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":172.460,"methodology":"fee schedule"}]}]},{"description":"Fibrinolytic factors and inhibitors; alpha-2 antiplasmin ","code_information":[{"code":"310","type":"RC"},{"code":"85410","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6.610,"maximum":26.820,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":26.820,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":26.820,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":6.610,"methodology":"fee schedule"}]}]},{"description":"SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS ","code_information":[{"code":"029","type":"MS-DRG"},{"code":"146","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC 2 Day Stay","code_information":[{"code":"113","type":"RC"},{"code":"421","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Antibody; Chlamydia ","code_information":[{"code":"307","type":"RC"},{"code":"86631","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.130,"maximum":41.170,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":41.170,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":41.170,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.820,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":10.130,"methodology":"fee schedule"}]}]},{"description":"Venography, renal, unilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"483","type":"RC"},{"code":"75831","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":123.040,"maximum":123.040,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":123.040,"methodology":"fee schedule"}]}]},{"description":"Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed with Cardiac Cath","code_information":[{"code":"93452","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7818.000,"maximum":7818.000,"payers_information":[{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":7818.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":7818.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":7818.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":7818.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":7818.000,"methodology":"case rate"}]}]},{"description":"Injection, octafluoropropane microspheres, per ml ","code_information":[{"code":"892","type":"RC"},{"code":"Q9956","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":66.350,"maximum":66.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":66.350,"methodology":"fee schedule"}]}]},{"description":"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"159","type":"RC"},{"code":"514","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, radial or ul ","code_information":[{"code":"35045","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3061.000,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Arthroscopy, elbow, surgical; with removal of loose body or foreign body ","code_information":[{"code":"29834","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":15410.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WIT ","code_information":[{"code":"133","type":"RC"},{"code":"495","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES 3 Day Stay","code_information":[{"code":"018","type":"MS-DRG"},{"code":"111","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"118","type":"RC"},{"code":"179","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"FOOT PROCEDURES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"119","type":"RC"},{"code":"505","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC 2 Day Stay","code_information":[{"code":"137","type":"RC"},{"code":"281","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC 3 Day Stay","code_information":[{"code":"159","type":"RC"},{"code":"476","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement) ","code_information":[{"code":"369","type":"RC"},{"code":"64449","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":365.660,"maximum":5055.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":430.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1534.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1916.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1916.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":2030.130,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2135.690,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2012.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2251.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2527.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2650.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2505.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":365.660,"methodology":"fee schedule"}]}]},{"description":"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC ","code_information":[{"code":"012","type":"MS-DRG"},{"code":"125","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Resection temporal bone, external approach ","code_information":[{"code":"490","type":"RC"},{"code":"69535","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":35773.410,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":26097.450,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":31847.730,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":31847.730,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":33810.570,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":35773.410,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC 4 Day Stay","code_information":[{"code":"139","type":"RC"},{"code":"722","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"126","type":"RC"},{"code":"346","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. ","code_information":[{"code":"156","type":"RC"},{"code":"828","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; electrode only ","code_information":[{"code":"0516T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":20098.070,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":14443.100,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":18034.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":18034.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":19104.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20098.070,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":9875.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16496.000,"methodology":"case rate"}]}]},{"description":"Delayed placement of distal extension prosthesis(es) from the level of the left subclavian artery to the celiac artery, after endovascular repair of descending thoracic aorta, including pre-procedure ","code_information":[{"code":"33886","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":12917.740,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9423.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11500.190,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11500.190,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12208.960,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12917.740,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"323","type":"RC"},{"code":"74170","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.950,"maximum":786.040,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":786.040,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":786.040,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":183.950,"methodology":"fee schedule"}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITH MCC 3 Day Stay","code_information":[{"code":"119","type":"RC"},{"code":"193","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Urethrocystography, voiding, radiological supervision and interpretation ","code_information":[{"code":"351","type":"RC"},{"code":"74455","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":107.360,"maximum":107.360,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":107.360,"methodology":"fee schedule"}]}]},{"description":"KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC ","code_information":[{"code":"126","type":"RC"},{"code":"486","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC 2 Day Stay","code_information":[{"code":"142","type":"RC"},{"code":"660","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Alveoplasty w/ extraction ","code_information":[{"code":"750","type":"RC"},{"code":"D7310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"APPENDIX PROCEDURES WITHOUT CC/MCC Pediatric","code_information":[{"code":"203","type":"RC"},{"code":"399","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":20405.000,"maximum":27283.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":20405.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":23121.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":27283.000,"methodology":"case rate"}]}]},{"description":"Scrotoplasty; simple ","code_information":[{"code":"480","type":"RC"},{"code":"55175","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6326.000,"maximum":6326.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC ","code_information":[{"code":"111","type":"RC"},{"code":"736","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s) ","code_information":[{"code":"611","type":"RC"},{"code":"72149","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":288.330,"maximum":3090.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3090.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2385.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2385.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":2265.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":2807.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1641.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":828.270,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":288.330,"methodology":"fee schedule"}]}]},{"description":"PROSTATECTOMY WITH CC ","code_information":[{"code":"137","type":"RC"},{"code":"666","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Unlisted laparoscopy procedure, testis ","code_information":[{"code":"54699","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2176.000,"maximum":4100.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":4100.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3162.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3162.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3004.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":3720.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2176.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, lumbar ","code_information":[{"code":"361","type":"RC"},{"code":"63277","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":21153.410,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":15431.850,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":18832.090,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":18832.090,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":19992.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":21153.410,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":9999.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":11331.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":13370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":9875.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":10949.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":13197.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":10185.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16496.000,"methodology":"case rate"}]}]},{"description":"Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) i ","code_information":[{"code":"C7552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":7223.000,"maximum":13607.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":13607.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":10498.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":10498.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":9975.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":12351.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":7223.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Enterotomy, small intestine, other than duodenum; for exploration, biopsy(s), or foreign body removal ","code_information":[{"code":"44020","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":13174.210,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9610.860,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11728.510,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11728.510,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12451.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13174.210,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC 3 Day Stay","code_information":[{"code":"127","type":"RC"},{"code":"507","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES 2 Day Stay","code_information":[{"code":"159","type":"RC"},{"code":"776","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"VIRAL ILLNESS WITHOUT MCC 2 Day Stay","code_information":[{"code":"141","type":"RC"},{"code":"866","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"CONNECTIVE TISSUE DISORDERS WITH MCC 3 Day Stay","code_information":[{"code":"124","type":"RC"},{"code":"545","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"MAJOR CHEST PROCEDURES WITH MCC ","code_information":[{"code":"155","type":"RC"},{"code":"163","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Cannabinoids, natural ","code_information":[{"code":"304","type":"RC"},{"code":"80349","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.500,"maximum":35.220,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":35.220,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":35.220,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":11.500,"methodology":"fee schedule"}]}]},{"description":"Echosclerotherapy ","code_information":[{"code":"360","type":"RC"},{"code":"S2202","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthrodesis, posterior or posterolateral technique, single interspace; thoracic (with lateral transverse technique, when performed) ","code_information":[{"code":"22610","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":28161.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":12512.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":15269.990,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":15269.990,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":16211.110,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17152.230,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":28161.000,"methodology":"case rate"}]}]},{"description":"WOUND DEBRIDEMENTS FOR INJURIES WITH CC 2 Day Stay","code_information":[{"code":"159","type":"RC"},{"code":"902","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"SKIN ULCERS WITHOUT CC/MCC ","code_information":[{"code":"101","type":"RC"},{"code":"594","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Removal of posterior segmental instrumentation ","code_information":[{"code":"22852","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":15581.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":6875.620,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":8390.590,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":8390.590,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":8907.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9424.850,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"}]}]},{"description":"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC ","code_information":[{"code":"139","type":"RC"},{"code":"392","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC ","code_information":[{"code":"111","type":"RC"},{"code":"522","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Oncology (prostate), mRNA, gene expression profiling by real-time RT-PCR of 17 genes (12 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm report as a risk scor ","code_information":[{"code":"0047U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3873.000,"maximum":3873.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3873.000,"methodology":"fee schedule"}]}]},{"description":"Radiation therapy management with complete course of therapy consisting of 1 or 2 fractions only ","code_information":[{"code":"323","type":"RC"},{"code":"77431","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":316.140,"maximum":316.140,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":316.140,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":316.140,"methodology":"fee schedule"}]}]},{"description":"Sinusotomy frontal; nonobliterative, with osteoplastic flap, coronal incision ","code_information":[{"code":"31087","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":595.000,"maximum":5069.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5069.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3911.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3911.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3716.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4601.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2692.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":2012.850,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2149.640,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":2149.640,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":2149.640,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":2149.640,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":1934.680,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":595.000,"methodology":"case rate"}]}]},{"description":"HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC 4 Day Stay","code_information":[{"code":"135","type":"RC"},{"code":"354","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC 3 Day Stay","code_information":[{"code":"136","type":"RC"},{"code":"629","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"116","type":"RC"},{"code":"804","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC 4 Day Stay","code_information":[{"code":"117","type":"RC"},{"code":"857","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Hepatic venography, wedged or free, with hemodynamic evaluation, radiological supervision and interpretation ","code_information":[{"code":"322","type":"RC"},{"code":"75889","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":126.440,"maximum":6438.740,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":431.610,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":431.610,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6438.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":126.440,"methodology":"fee schedule"}]}]},{"description":"Drainage of palmar bursa; multiple bursa 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case 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logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":23384.010,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":24771.200,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26059.300,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":9875.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":10949.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":13197.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":10185.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5851.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":3746.600,"methodology":"fee schedule"}]}]},{"description":"Biopsy of vaginal mucosa; extensive, requiring suture (including cysts) ","code_information":[{"code":"481","type":"RC"},{"code":"57105","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1141.200,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4721.410,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":5895.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":5895.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6245.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6570.000,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1141.200,"methodology":"fee schedule"}]}]},{"description":"Vitamin D, 25 hydroxy D2 and D3, by LC-MS/MS, serum microsample, quantitative ","code_information":[{"code":"0038U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":29.600,"maximum":29.600,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":29.600,"methodology":"fee schedule"}]}]},{"description":"OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"116","type":"RC"},{"code":"750","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Neutralization test, viral ","code_information":[{"code":"86382","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":14.480,"maximum":16.910,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16.910,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":14.480,"methodology":"fee schedule"}]}]},{"description":"SOFT TISSUE PROCEDURES WITH CC 4 Day Stay","code_information":[{"code":"121","type":"RC"},{"code":"501","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"093","type":"MS-DRG"},{"code":"122","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"013","type":"MS-DRG"},{"code":"119","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Removal of sutures or staples not requiring anesthesia (List separately in addition to E/M code) ","code_information":[{"code":"15853","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":5841.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH 3 Day Stay","code_information":[{"code":"141","type":"RC"},{"code":"618","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC ","code_information":[{"code":"112","type":"RC"},{"code":"320","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; each additional gestation (List separately in addition to code for primary procedure) ","code_information":[{"code":"74713","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":211.990,"maximum":211.990,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":211.990,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC ","code_information":[{"code":"10D07Z5","type":"ICD"},{"code":"112","type":"RC"},{"code":"807","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4598.000,"maximum":8660.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":8660.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":6682.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":6682.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":6348.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":7862.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":4598.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, single, each tendon or muscle ","code_information":[{"code":"25263","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15732.530,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11305.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14954.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15732.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2573.700,"methodology":"fee schedule"}]}]},{"description":"Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy ","code_information":[{"code":"369","type":"RC"},{"code":"57155","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1638.520,"maximum":30424.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1927.670,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8073.210,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":10080.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":10080.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":10678.850,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11234.150,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2012.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2251.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2527.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2650.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":30424.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1638.520,"methodology":"fee schedule"}]}]},{"description":"VEIN LIGATION AND STRIPPING 4 Day 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"}]}]},{"description":"ACUTE LEUKEMIA WITH CC 4 Day Stay","code_information":[{"code":"147","type":"RC"},{"code":"835","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Closed treatment of patellar dislocation; without anesthesia ","code_information":[{"code":"27560","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":91.560,"maximum":5841.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":407.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":508.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":508.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":539.100,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":567.130,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":91.560,"methodology":"fee schedule"}]}]},{"description":"Tracheostomy, emergency procedure; transtracheal ","code_information":[{"code":"31603","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":451.360,"maximum":5055.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2550.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3184.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3184.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3373.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3548.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2251.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2650.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":451.360,"methodology":"fee schedule"}]}]},{"description":"Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode(s) placement, recording, analysis and interpretation ","code_information":[{"code":"369","type":"RC"},{"code":"91034","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1672.000,"maximum":2940.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"142","type":"RC"},{"code":"630","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC ","code_information":[{"code":"123","type":"RC"},{"code":"863","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"ZRSR2 (zinc finger CCCH-type, RNA binding motif and serine/arginine-rich 2) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variant(s) (eg, E65fs, E122fs, R448fs) ","code_information":[{"code":"304","type":"RC"},{"code":"81360","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":193.250,"maximum":193.250,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":193.250,"methodology":"fee schedule"}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"096","type":"MS-DRG"},{"code":"123","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"EXTERNAL CIRCULATION ASSIST ","code_information":[{"code":"33961","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH MCC Adult","code_information":[{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":32217.000,"maximum":43077.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":32217.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 20.4% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":36506.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 23.1% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":43077.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 27.3% of billable gross charges instead of the contracted rate."}]}]},{"description":"LAP REMV GAST CURVE ELECTRD ","code_information":[{"code":"0156T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tmj reshaping components ","code_information":[{"code":"499","type":"RC"},{"code":"D7865","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC 4 Day Stay","code_information":[{"code":"167","type":"RC"},{"code":"744","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Absolute quantitation of myocardial blood flow (AQMBF), single-photon emission computed tomography (SPECT), with exercise or pharmacologic stress, and at rest, when performed (List separately in addit ","code_information":[{"code":"0742T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical ","code_information":[{"code":"22864","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":27957.390,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":20395.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":24889.420,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":24889.420,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":26423.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":27957.390,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"}]}]},{"description":"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"136","type":"RC"},{"code":"761","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC ","code_information":[{"code":"145","type":"RC"},{"code":"510","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC ","code_information":[{"code":"067","type":"MS-DRG"},{"code":"114","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Ultrasound, scrotum and contents ","code_information":[{"code":"352","type":"RC"},{"code":"76870","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":103.610,"maximum":103.610,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":103.610,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or d ","code_information":[{"code":"27198","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2946.000,"maximum":5055.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"141","type":"RC"},{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Ligation, division, and/or excision of varicose vein cluster(s), 1 leg ","code_information":[{"code":"367","type":"RC"},{"code":"37785","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"013","type":"MS-DRG"},{"code":"151","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS 3 Day Stay","code_information":[{"code":"029","type":"MS-DRG"},{"code":"136","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"RED BLOOD CELL DISORDERS WITH MCC 3 Day Stay","code_information":[{"code":"116","type":"RC"},{"code":"811","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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"}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WIT 2 Day Stay","code_information":[{"code":"119","type":"RC"},{"code":"495","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Open treatment of distal fibular fracture (lateral malleolus), includes internal fixation, when performed ","code_information":[{"code":"27792","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3437.830,"maximum":15732.530,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11305.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14954.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15732.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9124.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":3437.830,"methodology":"fee schedule"}]}]},{"description":"EXTRACRANIAL PROCEDURES WITH MCC 3 Day Stay","code_information":[{"code":"037","type":"MS-DRG"},{"code":"153","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC 3 Day Stay","code_information":[{"code":"159","type":"RC"},{"code":"448","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"PERICARDIOCENTESIS; SUBSEQUENT ","code_information":[{"code":"33011","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":422.000,"maximum":1472.990,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1472.990,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1472.990,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":422.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, colon, including scout abdominal radiograph(s) and delayed image(s), when performed; single-contrast (eg, barium) study ","code_information":[{"code":"611","type":"RC"},{"code":"74270","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":159.160,"maximum":159.160,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":159.160,"methodology":"fee schedule"}]}]},{"description":"Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening ","code_information":[{"code":"302","type":"RC"},{"code":"82272","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3.620,"maximum":11.930,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":11.930,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":11.930,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.230,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":3.620,"methodology":"fee schedule"}]}]},{"description":"VIRAL MENINGITIS WITHOUT CC/MCC ","code_information":[{"code":"076","type":"MS-DRG"},{"code":"160","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Insertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; without removal of crystalline lens or intraocular lens, without insertion of intraocular lens ","code_information":[{"code":"0616T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4807.000,"maximum":5055.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); less than 5 cm ","code_information":[{"code":"21556","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":5487.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PNEUMOTHORAX WITH CC 3 Day Stay","code_information":[{"code":"148","type":"RC"},{"code":"200","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Radiologic examination, wrist, arthrography, radiological supervision and interpretation ","code_information":[{"code":"610","type":"RC"},{"code":"73115","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":139.060,"maximum":139.060,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":139.060,"methodology":"fee schedule"}]}]},{"description":"CORONARY BYPASS WITH PTCA WITH MCC 4 Day Stay","code_information":[{"code":"154","type":"RC"},{"code":"231","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"UNCOMPLICATED PEPTIC ULCER WITHOUT MCC ","code_information":[{"code":"130","type":"RC"},{"code":"384","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC 2 Day Stay","code_information":[{"code":"115","type":"RC"},{"code":"847","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"OSTEOMYELITIS WITH CC 2 Day Stay","code_information":[{"code":"145","type":"RC"},{"code":"540","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCE 4 Day Stay","code_information":[{"code":"159","type":"RC"},{"code":"829","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Aminolevulinic acid, delta (ALA) ","code_information":[{"code":"312","type":"RC"},{"code":"82135","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.100,"maximum":57.270,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":57.270,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":57.270,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":14.100,"methodology":"fee schedule"}]}]},{"description":"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC A ","code_information":[{"code":"061","type":"MS-DRG"},{"code":"119","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"NERVOUS SYSTEM NEOPLASMS WITHOUT MCC 2 Day Stay","code_information":[{"code":"055","type":"MS-DRG"},{"code":"136","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC ","code_information":[{"code":"119","type":"RC"},{"code":"437","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES 2 Day Stay","code_information":[{"code":"121","type":"RC"},{"code":"212","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level ","code_information":[{"code":"22867","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":41938.190,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":30138.090,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":37632.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":37632.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":39865.200,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":41938.190,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":13197.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":10185.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, pharynx and/or cervical esophagus, including scout neck radiograph(s) and delayed image(s), when performed, contrast (eg, barium) study ","code_information":[{"code":"403","type":"RC"},{"code":"74210","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":99.510,"maximum":232.310,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":232.310,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":232.310,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":99.510,"methodology":"fee schedule"}]}]},{"description":"OTHER HEART ASSIST SYSTEM IMPLANT ","code_information":[{"code":"112","type":"RC"},{"code":"215","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. 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further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Puncture of shunt tubing or reservoir for aspiration or injection procedure ","code_information":[{"code":"481","type":"RC"},{"code":"61070","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":282.060,"maximum":5055.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1181.340,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1475.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1475.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1562.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1643.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2012.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2251.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2527.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2650.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2505.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":282.060,"methodology":"fee schedule"}]}]},{"description":"Dental coronoidectomy ","code_information":[{"code":"360","type":"RC"},{"code":"D7991","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Unlisted procedure, abdomen, musculoskeletal system ","code_information":[{"code":"22999","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":407.560,"maximum":7227.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":407.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":508.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":508.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":539.100,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":567.130,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"COMPLICATED PEPTIC ULCER WITH CC ","code_information":[{"code":"132","type":"RC"},{"code":"381","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Percutaneous transhepatic portography without hemodynamic evaluation, radiological supervision and interpretation ","code_information":[{"code":"343","type":"RC"},{"code":"75887","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":141.430,"maximum":473.310,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":473.310,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":473.310,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":141.430,"methodology":"fee schedule"}]}]},{"description":"Antibody; JC (John Cunningham) virus ","code_information":[{"code":"304","type":"RC"},{"code":"86711","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.890,"maximum":50.110,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":50.110,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":50.110,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16.890,"methodology":"fee schedule"}]}]},{"description":"SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS 2 Day Stay","code_information":[{"code":"029","type":"MS-DRG"},{"code":"135","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC ","code_information":[{"code":"113","type":"RC"},{"code":"360","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":2958.000,"payers_information":[{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC 4 Day Stay","code_information":[{"code":"146","type":"RC"},{"code":"584","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT ","code_information":[{"code":"155","type":"RC"},{"code":"933","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Terminal device, hand, mechanical, voluntary closing, any material, any size ","code_information":[{"code":"L6709","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1693.810,"maximum":18604.680,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1743.070,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":1728.380,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":1814.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":1728.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":1728.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":1728.380,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1728.380,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":1728.380,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":1728.380,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":1728.380,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":1728.380,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":3422.190,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":3456.760,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":1728.380,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":18604.680,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":1728.380,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":1728.380,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":1728.380,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":1728.380,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":18604.680,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":1728.380,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":1883.930,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":4199.960,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":3629.600,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":1814.800,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":1814.800,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":1832.080,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":1832.080,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":1832.080,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":1832.080,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":1832.080,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":1814.800,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":2678.990,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":1814.800,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":1814.800,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":1814.800,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":1728.380,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":1728.380,"methodology":"fee 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"}]}]},{"description":"CHEST PAIN 2 Day Stay","code_information":[{"code":"139","type":"RC"},{"code":"313","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITH MCC ","code_information":[{"code":"080","type":"MS-DRG"},{"code":"158","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITHOUT MCC 2 Day Stay","code_information":[{"code":"081","type":"MS-DRG"},{"code":"141","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Bone marrow harvesting for transplantation; allogeneic ","code_information":[{"code":"369","type":"RC"},{"code":"38230","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":605.860,"maximum":8328.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":712.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2501.640,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3123.740,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3123.740,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3309.050,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3481.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":605.860,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, stomach 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2066.970,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare 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rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"}]}]},{"description":"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC 3 Day Stay","code_information":[{"code":"120","type":"RC"},{"code":"537","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per 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"}]}]},{"description":"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"147","type":"RC"},{"code":"627","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Salicylate ","code_information":[{"code":"300","type":"RC"},{"code":"80179","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.970,"maximum":18.640,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":18.640,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":15.970,"methodology":"fee schedule"}]}]},{"description":"Ciliary body destruction; diathermy ","code_information":[{"code":"361","type":"RC"},{"code":"66700","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":912.020,"maximum":5487.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1072.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3821.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":4771.590,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":4771.590,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":5054.650,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5317.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health 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PROCEDURES WITH MCC ","code_information":[{"code":"141","type":"RC"},{"code":"820","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH CC 2 Day Stay","code_information":[{"code":"116","type":"RC"},{"code":"300","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC 3 Day Stay","code_information":[{"code":"113","type":"RC"},{"code":"147","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Influenza ","code_information":[{"code":"304","type":"RC"},{"code":"87804","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.180,"maximum":46.670,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":46.670,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":46.670,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16.550,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":14.180,"methodology":"fee schedule"}]}]},{"description":"ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC ","code_information":[{"code":"154","type":"RC"},{"code":"288","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"APPENDIX PROCEDURES WITH CC Adult","code_information":[{"code":"398","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":28285.000,"maximum":37821.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":28285.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 20.4% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":32051.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 23.1% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":37821.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 27.3% of billable gross charges instead of the contracted rate."}]}]},{"description":"Injection, pegcetacoplan, intravitreal, 1 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J2781","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":227.780,"maximum":227.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":227.780,"methodology":"fee schedule"}]}]},{"description":"Craniectomy for craniosynostosis; multiple cranial sutures ","code_information":[{"code":"480","type":"RC"},{"code":"61552","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC Pediatric","code_information":[{"code":"123","type":"RC"},{"code":"831","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10480.000,"maximum":14013.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":10480.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":11876.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":14013.000,"methodology":"case rate"}]}]},{"description":"LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC 3 Day Stay","code_information":[{"code":"142","type":"RC"},{"code":"821","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); bilateral ","code_information":[{"code":"481","type":"RC"},{"code":"69706","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3129.770,"maximum":13376.310,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9612.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12003.080,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12003.080,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12715.130,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13376.310,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":3129.770,"methodology":"fee schedule"}]}]},{"description":"Suture of major peripheral nerve, arm or leg, except sciatic; including transposition ","code_information":[{"code":"367","type":"RC"},{"code":"64856","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":5487.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Suture of nerve; requiring shortening of bone of extremity (List separately in addition to code for nerve suture) ","code_information":[{"code":"64876","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":482.000,"maximum":4100.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":4100.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3162.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3162.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3004.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":3720.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2176.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":482.000,"methodology":"case rate"}]}]},{"description":"PLEURAL EFFUSION WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"188","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EX ","code_information":[{"code":"137","type":"RC"},{"code":"457","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC ","code_information":[{"code":"100","type":"RC"},{"code":"10D07Z6","type":"ICD"},{"code":"798","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1422.000,"maximum":2678.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":2678.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1964.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":2433.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1422.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "}]}]},{"description":"HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC 2 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"522","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"122","type":"RC"},{"code":"514","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"146","type":"RC"},{"code":"282","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; High Cost Surgery","code_information":[{"code":"361","type":"RC"},{"code":"58553","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2369.000,"maximum":2369.000,"payers_information":[{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":2369.000,"methodology":"case rate"}]}]},{"description":"HEART FAILURE AND SHOCK WITH CC 3 Day Stay","code_information":[{"code":"149","type":"RC"},{"code":"292","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"MAJOR HEAD AND NECK PROCEDURES WITH MCC Pediatric","code_information":[{"code":"140","type":"MS-DRG"},{"code":"203","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":18624.000,"maximum":24903.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":18624.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":21104.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":24903.000,"methodology":"case rate"}]}]},{"description":"Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, trunk, arms, legs; first 480 sq cm or less ","code_information":[{"code":"15015","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3457.240,"maximum":4810.870,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3457.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":4316.980,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":4316.980,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":4573.070,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4810.870,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"}]}]},{"description":"RENAL FAILURE WITHOUT CC/MCC ","code_information":[{"code":"136","type":"RC"},{"code":"684","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"117","type":"RC"},{"code":"561","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES ","code_information":[{"code":"139","type":"RC"},{"code":"844","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"TYMS (thymidylate synthetase) (eg, 5-fluorouracil/5-FU drug metabolism), gene analysis, common variant(s) (eg, tandem repeat variant) ","code_information":[{"code":"309","type":"RC"},{"code":"81346","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":174.810,"maximum":492.960,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":492.960,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":492.960,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":174.810,"methodology":"fee schedule"}]}]},{"description":"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC 2 Day Stay","code_information":[{"code":"149","type":"RC"},{"code":"760","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Excision of parotid tumor or parotid gland; total, en bloc removal with sacrifice of facial nerve ","code_information":[{"code":"42425","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12756.890,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9167.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11447.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11447.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12126.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12756.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7577.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8586.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":10131.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2096.960,"methodology":"fee schedule"}]}]},{"description":"Subcutaneous injection of filling material (eg, collagen); 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"}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC 4 Day Stay","code_information":[{"code":"119","type":"RC"},{"code":"964","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"121","type":"RC"},{"code":"561","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"EXTRACRANIAL PROCEDURES WITH CC 3 Day Stay","code_information":[{"code":"038","type":"MS-DRG"},{"code":"119","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s) ","code_information":[{"code":"731","type":"RC"},{"code":"73221","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":215.400,"maximum":215.400,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":215.400,"methodology":"fee schedule"}]}]},{"description":"COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC ","code_information":[{"code":"148","type":"RC"},{"code":"430","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"151","type":"RC"},{"code":"759","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Splenoportography, radiological supervision and interpretation ","code_information":[{"code":"322","type":"RC"},{"code":"75810","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":624.840,"maximum":6438.740,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1877.550,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1877.550,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6438.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":624.840,"methodology":"fee schedule"}]}]},{"description":"INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC 2 Day Stay","code_information":[{"code":"020","type":"MS-DRG"},{"code":"132","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC ","code_information":[{"code":"123","type":"RC"},{"code":"584","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"ANAL AND STOMAL PROCEDURES WITH CC 3 Day Stay","code_information":[{"code":"110","type":"RC"},{"code":"348","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"OTHER O.R. 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"}]}]},{"description":"Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps ","code_information":[{"code":"29823","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":15581.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1373.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9124.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES 3 Day Stay","code_information":[{"code":"144","type":"RC"},{"code":"483","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"REPAIR OF TENNIS ELBOW ","code_information":[{"code":"24352","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH MCC 2 Day Stay","code_information":[{"code":"100","type":"RC"},{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Sclerotherapy of a fluid collection (eg, lymphocele, cyst, or seroma), percutaneous, including contrast injection(s), sclerosant injection(s), diagnostic study, imaging guidance (eg, ultrasound, fluor ","code_information":[{"code":"481","type":"RC"},{"code":"49185","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1152.920,"maximum":10131.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1152.920,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1439.620,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1439.620,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1525.030,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1604.330,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7577.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8586.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":10131.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2012.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2505.000,"methodology":"case rate"}]}]},{"description":"UPPER GI ENDOSCOPY W/SUTURE ","code_information":[{"code":"0008T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC 3 Day Stay","code_information":[{"code":"164","type":"RC"},{"code":"516","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Fibrin degradation products, D-dimer; ultrasensitive (eg, for evaluation for venous thromboembolism), qualitative or semiquantitative ","code_information":[{"code":"85380","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8.720,"maximum":10.180,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10.180,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":8.720,"methodology":"fee schedule"}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC ","code_information":[{"code":"134","type":"RC"},{"code":"390","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Neomatrix, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"891","type":"RC"},{"code":"A2021","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, mediastinum ","code_information":[{"code":"39499","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":13988.660,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10205.020,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12453.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12453.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13221.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13988.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"129","type":"RC"},{"code":"156","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"122","type":"RC"},{"code":"905","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC ","code_information":[{"code":"154","type":"RC"},{"code":"578","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Radiologic examination, shoulder, arthrography, radiological supervision and interpretation ","code_information":[{"code":"73040","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":134.960,"maximum":134.960,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":134.960,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, elbow, arthrography, radiological supervision and interpretation ","code_information":[{"code":"322","type":"RC"},{"code":"73085","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":114.510,"maximum":828.270,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":286.630,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":286.630,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":828.270,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":114.510,"methodology":"fee schedule"}]}]},{"description":"OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC ","code_information":[{"code":"114","type":"RC"},{"code":"229","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"URETHRAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"164","type":"RC"},{"code":"672","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC ","code_information":[{"code":"157","type":"RC"},{"code":"657","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"132","type":"RC"},{"code":"581","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study ","code_information":[{"code":"614","type":"RC"},{"code":"93931","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":111.150,"maximum":111.150,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":111.150,"methodology":"fee schedule"}]}]},{"description":"Antibody; Haemophilus influenza ","code_information":[{"code":"314","type":"RC"},{"code":"86684","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.580,"maximum":55.160,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":55.160,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":55.160,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":13.580,"methodology":"fee schedule"}]}]},{"description":"MAJOR ESOPHAGEAL DISORDERS WITH MCC 4 Day Stay","code_information":[{"code":"146","type":"RC"},{"code":"368","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"ENDOCRINE DISORDERS WITHOUT CC/MCC Pediatric","code_information":[{"code":"645","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12797.960,"maximum":16455.730,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":12797.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14392.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14392.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":15424.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16455.730,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS ","code_information":[{"code":"133","type":"RC"},{"code":"207","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC ","code_information":[{"code":"131","type":"RC"},{"code":"656","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"158","type":"RC"},{"code":"833","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, continuous infusion by catheter (including catheter placement), including imaging guidance, when performed ","code_information":[{"code":"360","type":"RC"},{"code":"64416","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":365.660,"maximum":5055.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":430.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1534.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1916.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1916.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":2030.130,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2135.690,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2012.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2251.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2527.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2650.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2505.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":365.660,"methodology":"fee schedule"}]}]},{"description":"COMPLEX AORTIC ARCH PROCEDURES ","code_information":[{"code":"125","type":"RC"},{"code":"209","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"060","type":"MS-DRG"},{"code":"101","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"INSERTION OR REPLACEMENT OF A PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM, ENDOVASCULAR APPROACH, AND PROGRAMMING OF SENSING AND THERAPEUTIC PARAMETERS; MECHANO-ELECTRICA ","code_information":[{"code":"0453T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC 2 Day Stay","code_information":[{"code":"127","type":"RC"},{"code":"510","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"72130","type":"CPT"},{"code":"929","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":183.950,"maximum":183.950,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":183.950,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, pelvic (nonobstetric), real time with image documentation; complete ","code_information":[{"code":"76856","type":"CPT"},{"code":"920","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":98.210,"maximum":98.210,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":98.210,"methodology":"fee schedule"}]}]},{"description":"TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"142","type":"RC"},{"code":"714","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy ","code_information":[{"code":"19302","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1979.980,"maximum":13774.070,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9898.480,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12360.000,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12360.000,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13093.230,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13774.070,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7577.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8586.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":10131.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1979.980,"methodology":"fee schedule"}]}]},{"description":"NON-EXTENSIVE BURNS 4 Day Stay","code_information":[{"code":"160","type":"RC"},{"code":"935","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH 2 Day Stay","code_information":[{"code":"115","type":"RC"},{"code":"410","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC ","code_information":[{"code":"136","type":"RC"},{"code":"555","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"OTHER FACTORS INFLUENCING HEALTH STATUS 3 Day Stay","code_information":[{"code":"145","type":"RC"},{"code":"951","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES 4 Day Stay","code_information":[{"code":"116","type":"RC"},{"code":"278","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1604.330,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative 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"}]}]},{"description":"GASTROINTESTINAL HEMORRHAGE WITH MCC ","code_information":[{"code":"139","type":"RC"},{"code":"377","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Osteotomy, femoral neck (separate procedure) ","code_information":[{"code":"27161","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER RESPIRATORY SYSTEM O.R. 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"}]}]},{"description":"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC ","code_information":[{"code":"160","type":"RC"},{"code":"604","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC ","code_information":[{"code":"128","type":"RC"},{"code":"351","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Radiologic examination, elbow, arthrography, radiological supervision and interpretation ","code_information":[{"code":"352","type":"RC"},{"code":"73085","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":114.510,"maximum":114.510,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":114.510,"methodology":"fee schedule"}]}]},{"description":"Dynamic cavernosometry, including intracavernosal injection of vasoactive drugs (eg, papaverine, phentolamine) ","code_information":[{"code":"54231","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3061.000,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"136","type":"RC"},{"code":"965","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contras ","code_information":[{"code":"36903","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":26059.300,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":18727.030,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":23384.010,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":23384.010,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":24771.200,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26059.300,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":9875.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":10694.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":10185.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16496.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":5655.010,"methodology":"fee schedule"}]}]},{"description":"Pulmonary ventilation (eg, aerosol or gas) and perfusion imaging ","code_information":[{"code":"78582","type":"CPT"},{"code":"924","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":333.650,"maximum":333.650,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":333.650,"methodology":"fee schedule"}]}]},{"description":"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC ","code_information":[{"code":"580","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1275.000,"maximum":4488.000,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":1275.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4488.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $552131.00, reimbursement will be $6139 per diem instead of the contracted rate."}]}]},{"description":"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"124","type":"RC"},{"code":"434","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC ","code_information":[{"code":"060","type":"MS-DRG"},{"code":"116","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"125","type":"RC"},{"code":"395","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"ENDOCRINE DISORDERS WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"152","type":"RC"},{"code":"645","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Rheumatoid factor; quantitative ","code_information":[{"code":"306","type":"RC"},{"code":"86431","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.860,"maximum":19.740,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":19.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":19.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.670,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":4.860,"methodology":"fee schedule"}]}]},{"description":"BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. 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rate"}]}]},{"description":"Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar ","code_information":[{"code":"480","type":"RC"},{"code":"63030","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9124.000,"maximum":9124.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9124.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC ","code_information":[{"code":"117","type":"RC"},{"code":"604","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per 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"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (eg, to assess for residual tumor or residual vascular malformation); without c ","code_information":[{"code":"70557","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1123.990,"maximum":1855.080,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1123.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1467.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1467.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1661.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1855.080,"methodology":"fee schedule"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC 4 Day Stay","code_information":[{"code":"169","type":"RC"},{"code":"831","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"PNEUMOTHORAX WITH MCC 3 Day Stay","code_information":[{"code":"152","type":"RC"},{"code":"199","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC 3 Day Stay","code_information":[{"code":"136","type":"RC"},{"code":"521","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH MCC 3 Day Stay","code_information":[{"code":"152","type":"RC"},{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE ","code_information":[{"code":"111","type":"RC"},{"code":"325","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC 4 Day Stay","code_information":[{"code":"111","type":"RC"},{"code":"167","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Resection or excision of neoplastic, vascular or infectious lesion of base of posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies; extradural ","code_information":[{"code":"480","type":"RC"},{"code":"61615","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hospital outpatient clinic visit for assessment and management of a patient ","code_information":[{"code":"760","type":"RC"},{"code":"G0463","type":"HCPCS"}],"standard_charges":[{"modifiers":"25","modifiers_description":"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service","setting":"outpatient","minimum":4060.000,"maximum":4060.000,"payers_information":[{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":4060.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination; clavicle, complete ","code_information":[{"code":"342","type":"RC"},{"code":"73000","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":33.060,"maximum":83.480,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":83.480,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":83.480,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":33.060,"methodology":"fee schedule"}]}]},{"description":"MINOR BLADDER PROCEDURES WITH MCC 2 Day Stay","code_information":[{"code":"146","type":"RC"},{"code":"662","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or first gestation ","code_information":[{"code":"341","type":"RC"},{"code":"74712","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":238.190,"maximum":1479.070,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1479.070,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1479.070,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":238.190,"methodology":"fee schedule"}]}]},{"description":"Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), clavicle ","code_information":[{"code":"23180","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4988.000,"maximum":4988.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC 3 Day Stay","code_information":[{"code":"131","type":"RC"},{"code":"424","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac); each additional lesion with separate injection (List separately in addition to code for primary procedure) ","code_information":[{"code":"343","type":"RC"},{"code":"76979","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":171.090,"maximum":171.090,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":171.090,"methodology":"fee schedule"}]}]},{"description":"POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. 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"}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; Legionella pneumophila ","code_information":[{"code":"303","type":"RC"},{"code":"87278","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.360,"maximum":43.990,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":43.990,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":43.990,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15.600,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":13.360,"methodology":"fee schedule"}]}]},{"description":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZA 4 Day Stay","code_information":[{"code":"130","type":"RC"},{"code":"217","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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"}]}]},{"description":"CERVICAL SPINAL FUSION WITHOUT CC/MCC ","code_information":[{"code":"135","type":"RC"},{"code":"473","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. 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"}]}]},{"description":"Consultation and report on referred slides prepared elsewhere ","code_information":[{"code":"304","type":"RC"},{"code":"88321","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":287.160,"maximum":287.160,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":287.160,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":287.160,"methodology":"fee schedule"}]}]},{"description":"OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC ","code_information":[{"code":"146","type":"RC"},{"code":"868","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Peanut allergen-specific quantitative assessment of multiple epitopes using enzyme-linked immunosorbent assay (ELISA), blood, report of minimum eliciting exposure for a clinical reaction ","code_information":[{"code":"0178U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":459.860,"maximum":459.860,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":459.860,"methodology":"fee schedule"}]}]},{"description":"Intra-operative epicardial and endocardial pacing and mapping to localize the site of tachycardia or zone of slow conduction for surgical correction ","code_information":[{"code":"480","type":"RC"},{"code":"93631","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":43890.000,"maximum":43890.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":43890.000,"methodology":"case rate"}]}]},{"description":"Excision of lesion, cornea (keratectomy, lamellar, partial), except pterygium ","code_information":[{"code":"367","type":"RC"},{"code":"65400","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2946.000,"maximum":5055.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MALIGNANT BREAST DISORDERS WITH MCC 3 Day Stay","code_information":[{"code":"132","type":"RC"},{"code":"597","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES ","code_information":[{"code":"1761","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5358.890,"maximum":6244.070,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":6244.070,"methodology":"fee schedule"},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":5575.410,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":5683.670,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":5683.670,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":5683.670,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":5683.670,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":6106.460,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":6106.460,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":6106.460,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":6106.460,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":6106.460,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":5358.890,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":5521.280,"methodology":"fee schedule"}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCE ","code_information":[{"code":"141","type":"RC"},{"code":"829","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"MINOR SKIN DISORDERS WITH MCC 2 Day Stay","code_information":[{"code":"147","type":"RC"},{"code":"606","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITH CC ","code_information":[{"code":"115","type":"RC"},{"code":"975","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Removal of subdeltoid calcareous deposits, open ","code_information":[{"code":"23000","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":422.000,"maximum":3589.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3589.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2768.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2768.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":2630.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":3257.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1904.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6181.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6548.230,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6888.730,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1604.330,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative 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"}]}]},{"description":"Radical resection of tumor; clavicle ","code_information":[{"code":"23200","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":20351.380,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":14846.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":18118.080,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":18118.080,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":19234.730,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20351.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"}]}]},{"description":"CONCUSSION WITH MCC 2 Day Stay","code_information":[{"code":"088","type":"MS-DRG"},{"code":"117","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report ","code_information":[{"code":"340","type":"RC"},{"code":"93315","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":360.100,"maximum":360.100,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":360.100,"methodology":"fee schedule"}]}]},{"description":"CHOLECYSTECTOMY WITH C.D.E. WITH MCC 4 Day Stay","code_information":[{"code":"124","type":"RC"},{"code":"411","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"OTHER CIRCULATORY SYSTEM O.R. 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"}]}]},{"description":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETER ","code_information":[{"code":"120","type":"RC"},{"code":"220","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test ","code_information":[{"code":"89330","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10.380,"maximum":10.380,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10.380,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"132","type":"RC"},{"code":"756","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC ","code_information":[{"code":"131","type":"RC"},{"code":"274","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Sulfate, urine ","code_information":[{"code":"84392","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.560,"maximum":20.060,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":5.540,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":4.980,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":5.490,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":5.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":12.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":15.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":15.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":16.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":5.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":5.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":5.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17.240,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":14.990,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":17.030,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":20.060,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":5.490,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":5.490,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":5.490,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":5.490,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":5.490,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":10.870,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":4.750,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":10.980,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":14.240,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":5.490,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":5.490,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":5.490,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":5.490,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":5.490,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":5.490,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":5.980,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":5.070,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":13.340,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":5.070,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":5.070,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":5.070,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":11.530,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":12.900,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":5.760,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":5.760,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":5.820,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":5.820,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":5.820,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":5.820,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":5.820,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":5.760,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":8.510,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":5.760,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":5.760,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":5.760,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":4.560,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":5.940,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":5.490,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":5.600,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":6.590,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":5.380,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, lower extremity; 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schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14568.310,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":15466.180,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16364.050,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"}]}]},{"description":"Colectomy, partial, with removal of terminal ileum with ileocolostomy ","code_information":[{"code":"44160","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":16793.140,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":12250.950,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14950.310,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14950.310,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":15871.730,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16793.140,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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"}]}]},{"description":"Helicobacter pylori, blood test analysis for urease activity, non-radioactive isotope (eg, C-13) ","code_information":[{"code":"306","type":"RC"},{"code":"83009","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":57.710,"maximum":234.510,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":234.510,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":234.510,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":67.360,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":57.710,"methodology":"fee schedule"}]}]},{"description":"ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC 4 Day Stay","code_information":[{"code":"123","type":"RC"},{"code":"288","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC 2 Day Stay","code_information":[{"code":"073","type":"MS-DRG"},{"code":"167","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Dilation of lacrimal punctum, with or without irrigation ","code_information":[{"code":"360","type":"RC"},{"code":"68801","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":687.190,"maximum":5841.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":687.190,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":858.070,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":858.070,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":908.970,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":956.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC 2 Day Stay","code_information":[{"code":"146","type":"RC"},{"code":"461","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Radiologic examination, spine; thoracic, minimum of 4 views ","code_information":[{"code":"72074","type":"CPT"},{"code":"739","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":45.330,"maximum":45.330,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":45.330,"methodology":"fee schedule"}]}]},{"description":"Urethroplasty, transpubic or perineal, 1-stage, for reconstruction or repair of prostatic or membranous urethra ","code_information":[{"code":"53415","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3061.000,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"BRONCHITIS AND ASTHMA WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"164","type":"RC"},{"code":"203","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC 4 Day Stay","code_information":[{"code":"132","type":"RC"},{"code":"229","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Injection, alglucosidase alfa, (lumizyme), 10 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J0221","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":342.190,"maximum":342.190,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":342.190,"methodology":"fee schedule"}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC ","code_information":[{"code":"131","type":"RC"},{"code":"657","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"ACUTE LEUKEMIA WITHOUT CC/MCC ","code_information":[{"code":"135","type":"RC"},{"code":"836","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Repair of transposition of the great arteries with ventricular septal defect and subpulmonary stenosis; without surgical enlargement of ventricular septal defect ","code_information":[{"code":"33770","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":28712.950,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":20946.700,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":25562.070,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":25562.070,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":27137.510,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":28712.950,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC ","code_information":[{"code":"164","type":"RC"},{"code":"250","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC 4 Day Stay","code_information":[{"code":"130","type":"RC"},{"code":"284","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC 3 Day Stay","code_information":[{"code":"056","type":"MS-DRG"},{"code":"136","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"ATHEROSCLEROSIS WITHOUT MCC 4 Day Stay","code_information":[{"code":"144","type":"RC"},{"code":"303","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Sympathectomy; superficial palmar arch ","code_information":[{"code":"369","type":"RC"},{"code":"64823","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":15410.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1373.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"146","type":"RC"},{"code":"168","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITH CC 4 Day Stay","code_information":[{"code":"112","type":"RC"},{"code":"389","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Closed treatment of tarsometatarsal joint dislocation; requiring anesthesia ","code_information":[{"code":"28605","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":91.560,"maximum":5841.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":407.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":508.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":508.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":539.100,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":567.130,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":91.560,"methodology":"fee schedule"}]}]},{"description":"Injection, labetalol hydrochloride (hikma), not therapeutically equivalent to j1920, 5 mg ","code_information":[{"code":"J1921","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1.380,"maximum":3.620,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":2.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":2.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3.200,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2.690,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3.060,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3.620,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":1.380,"methodology":"fee schedule"}]}]},{"description":"Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into pharynx ","code_information":[{"code":"369","type":"RC"},{"code":"42815","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2096.960,"maximum":12756.890,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":2467.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9167.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11447.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11447.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12126.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12756.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7367.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8349.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2096.960,"methodology":"fee schedule"}]}]},{"description":"HMuscle, myocutaneous, or fasciocutaneous flap; head and neck (eg, temporalis, masseter muscle, sternocleidomastoid, levator scapulae) ","code_information":[{"code":"15732","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2434.000,"maximum":5055.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"}]}]},{"description":"REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"155","type":"RC"},{"code":"468","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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"}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC ","code_information":[{"code":"152","type":"RC"},{"code":"964","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Application, cast; figure-of-eight ","code_information":[{"code":"29049","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":50.150,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":52.180,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":55.730,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":55.730,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":55.730,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":55.730,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":50.150,"methodology":"fee schedule"}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITH CC 2 Day Stay","code_information":[{"code":"100","type":"RC"},{"code":"194","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC ","code_information":[{"code":"160","type":"RC"},{"code":"244","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"132","type":"RC"},{"code":"407","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"APPENDIX PROCEDURES WITH MCC ","code_information":[{"code":"126","type":"RC"},{"code":"397","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"ORBITAL PROCEDURES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"112","type":"RC"},{"code":"114","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC ","code_information":[{"code":"118","type":"RC"},{"code":"261","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"CHEST PAIN 2 Day Stay","code_information":[{"code":"150","type":"RC"},{"code":"313","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISOR 3 Day Stay","code_information":[{"code":"119","type":"RC"},{"code":"622","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Blood count; reticulocytes, automated, including 1 or more cellular parameters (eg, reticulocyte hemoglobin content ºCHr», immature reticulocyte fraction ºIRF», reticulocyte volume ºMRV», RNA content) ","code_information":[{"code":"306","type":"RC"},{"code":"85046","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.770,"maximum":19.400,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":19.400,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":19.400,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.570,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":4.770,"methodology":"fee schedule"}]}]},{"description":"CERVICAL SPINAL FUSION WITH CC ","code_information":[{"code":"146","type":"RC"},{"code":"472","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) (eg, gastrointestinal stromal tumor ºGIST»), gene analysis, targeted sequence analysis (eg, exons 12, 18) ","code_information":[{"code":"302","type":"RC"},{"code":"81314","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":282.330,"maximum":929.220,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":929.220,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":929.220,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":329.510,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":282.330,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy; with incision or resection of orifice of bladder diverticulum, single or multiple ","code_information":[{"code":"362","type":"RC"},{"code":"52305","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":5487.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Genetic testing for amyotrophic lateral sclerosis (als) ","code_information":[{"code":"S3800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITH MCC ","code_information":[{"code":"149","type":"RC"},{"code":"444","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"RECTAL RESECTION WITHOUT CC/MCC ","code_information":[{"code":"100","type":"RC"},{"code":"334","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Insertion of ocular implant secondary; after evisceration, in scleral shell ","code_information":[{"code":"369","type":"RC"},{"code":"65130","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1184.020,"maximum":15410.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1392.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5910.140,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7379.860,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7379.860,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7817.650,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8224.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1184.020,"methodology":"fee schedule"}]}]},{"description":"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISOR 4 Day Stay","code_information":[{"code":"144","type":"RC"},{"code":"622","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"EPISTAXIS WITHOUT MCC 3 Day Stay","code_information":[{"code":"113","type":"RC"},{"code":"151","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Repair fistula; oronasal ","code_information":[{"code":"30600","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":8444.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope or telescope ","code_information":[{"code":"31541","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1139.830,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5550.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6931.110,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6931.110,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7342.270,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7724.070,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1139.830,"methodology":"fee schedule"}]}]},{"description":"Esophagoscopy, flexible, transnasal; with biopsy, single or multiple ","code_information":[{"code":"43198","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":128.620,"maximum":7037.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":858.940,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1048.050,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1048.050,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1113.020,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1177.980,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":128.620,"methodology":"fee schedule"}]}]},{"description":"Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cm ","code_information":[{"code":"12037","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":760.800,"maximum":5487.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":895.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3066.980,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3829.670,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3829.670,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":4056.850,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4267.810,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2251.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2527.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2650.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":760.800,"methodology":"fee schedule"}]}]},{"description":"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT C 2 Day Stay","code_information":[{"code":"136","type":"RC"},{"code":"443","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHE 4 Day Stay","code_information":[{"code":"155","type":"RC"},{"code":"838","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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"}]}]},{"description":"Unlisted procedure, arthroscopy ","code_information":[{"code":"29999","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":407.560,"maximum":8328.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":407.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":508.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":508.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":539.100,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":567.130,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case 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multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"PERCUT VERTEBROPLASTY THOR ","code_information":[{"code":"22520","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Venography, caval, inferior, with serialography, 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"}]}]},{"description":"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES ","code_information":[{"code":"130","type":"RC"},{"code":"845","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WIT 2 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"495","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; sacral ","code_information":[{"code":"360","type":"RC"},{"code":"63273","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":25401.870,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":18531.190,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":22614.340,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":22614.340,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":24008.100,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25401.870,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":9999.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":11331.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":13370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"150","type":"RC"},{"code":"578","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHE ","code_information":[{"code":"149","type":"RC"},{"code":"838","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; ","code_information":[{"code":"369","type":"RC"},{"code":"52005","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":700.490,"maximum":12635.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":824.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3348.230,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":4180.860,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":4180.860,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":4428.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4659.180,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":700.490,"methodology":"fee schedule"}]}]},{"description":"OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS ","code_information":[{"code":"6513","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8502.530,"maximum":9906.970,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":9906.970,"methodology":"fee schedule"},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":8846.060,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":9017.830,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":9017.830,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":9017.830,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":9017.830,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":8970.960,"methodology":"fee 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"}]}]},{"description":"Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or d ","code_information":[{"code":"27198","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":91.560,"maximum":5841.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":107.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":407.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":508.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":508.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":539.100,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":567.130,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":91.560,"methodology":"fee schedule"}]}]},{"description":"LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT 3 Day Stay","code_information":[{"code":"005","type":"MS-DRG"},{"code":"110","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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"}]}]},{"description":"Partial laryngectomy (hemilaryngectomy); antero-latero-vertical ","code_information":[{"code":"31382","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (colorectal cancer), eval for mutations of APC, BRAF, CTNNB1, KRAS, NRAS, IPK3CA, SMAD4, and TP53, and methylation markers, multiplex quantitative polymerase chain reaction (qPCR), circulatin ","code_information":[{"code":"0368U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":416.780,"maximum":416.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":416.780,"methodology":"fee schedule"}]}]},{"description":"CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC 2 Day Stay","code_information":[{"code":"155","type":"RC"},{"code":"324","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Venous thrombosis imaging, venogram; bilateral ","code_information":[{"code":"409","type":"RC"},{"code":"78458","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":205.850,"maximum":630.940,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":630.940,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":630.940,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":205.850,"methodology":"fee schedule"}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC ","code_information":[{"code":"066","type":"MS-DRG"},{"code":"101","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALL ","code_information":[{"code":"167","type":"RC"},{"code":"447","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Injection, interferon beta-1a, 1 mcg for intramuscular use ","code_information":[{"code":"892","type":"RC"},{"code":"Q3027","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":285.620,"maximum":285.620,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":285.620,"methodology":"fee schedule"}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC 4 Day Stay","code_information":[{"code":"144","type":"MS-DRG"},{"code":"152","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC ","code_information":[{"code":"026","type":"MS-DRG"},{"code":"101","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"MAJOR ESOPHAGEAL DISORDERS WITH CC 2 Day Stay","code_information":[{"code":"160","type":"RC"},{"code":"369","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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"}]}]},{"description":"KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC ","code_information":[{"code":"119","type":"RC"},{"code":"486","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"CHOLECYSTECTOMY WITH C.D.E. WITH MCC 4 Day Stay","code_information":[{"code":"123","type":"RC"},{"code":"411","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC 4 Day Stay","code_information":[{"code":"140","type":"RC"},{"code":"757","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"AFTERCARE WITH CC/MCC 3 Day Stay","code_information":[{"code":"120","type":"RC"},{"code":"949","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"110","type":"RC"},{"code":"310","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"WOUND DEBRIDEMENTS FOR INJURIES WITH MCC ","code_information":[{"code":"140","type":"RC"},{"code":"901","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"122","type":"RC"},{"code":"759","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Kidney imaging morphology; with vascular flow ","code_information":[{"code":"732","type":"RC"},{"code":"78701","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":220.840,"maximum":220.840,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":220.840,"methodology":"fee schedule"}]}]},{"description":"CARDIAC ARREST, UNEXPLAINED WITH MCC 3 Day Stay","code_information":[{"code":"164","type":"RC"},{"code":"296","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Decompression fasciotomy, thigh and/or knee, 1 compartment (flexor or extensor or adductor); ","code_information":[{"code":"27496","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":678.000,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":1120.920,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1197.100,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1197.100,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1197.100,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1197.100,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":1077.390,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":678.000,"methodology":"case rate"}]}]},{"description":"SPLENIC PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"101","type":"RC"},{"code":"801","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Spleen imaging only, with or without vascular flow ","code_information":[{"code":"730","type":"RC"},{"code":"78185","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":172.110,"maximum":172.110,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":172.110,"methodology":"fee schedule"}]}]},{"description":"NONTRAUMATIC SPINAL CORD INJURY; M > 40.15 & M < 5 ","code_information":[{"code":"138","type":"RC"},{"code":"A0502","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":18457.190,"maximum":20118.330,"payers_information":[{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":18457.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":18457.190,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":20118.330,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":19380.050,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":18826.330,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":18826.330,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":18826.330,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":18826.330,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":18826.330,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":19380.050,"methodology":"fee schedule"}]}]},{"description":"HAND PROCEDURES FOR INJURIES ","code_information":[{"code":"136","type":"RC"},{"code":"906","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Unlisted laparoscopy procedure, ureter High Cost Surgery","code_information":[{"code":"361","type":"RC"},{"code":"50949","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2369.000,"maximum":2369.000,"payers_information":[{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":2369.000,"methodology":"case rate"}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITHOUT MCC ","code_information":[{"code":"081","type":"MS-DRG"},{"code":"122","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES ","code_information":[{"code":"116","type":"RC"},{"code":"748","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC ","code_information":[{"code":"152","type":"RC"},{"code":"559","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC ","code_information":[{"code":"001","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":197254.000,"maximum":197254.000,"payers_information":[{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":197254.000,"methodology":"fee schedule"}]}]},{"description":"ENDOCRINE DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"113","type":"RC"},{"code":"645","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with complex repair ","code_information":[{"code":"11471","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":5487.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement application ","code_information":[{"code":"369","type":"RC"},{"code":"55920","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4988.000,"maximum":15410.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8073.210,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":10080.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":10080.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":10678.850,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11234.150,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":9999.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":11331.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":13370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"}]}]},{"description":"CELLULITIS WITH MCC 3 Day Stay","code_information":[{"code":"155","type":"RC"},{"code":"602","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Repair cleft hand ","code_information":[{"code":"26580","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":9851.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7367.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8349.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"BURNS; M=12-45 ","code_information":[{"code":"148","type":"RC"},{"code":"B2102","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":43873.530,"maximum":47822.140,"payers_information":[{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":43873.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":43873.530,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":47822.140,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":46067.200,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":44751.000,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":44751.000,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":44751.000,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":44751.000,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":44751.000,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":46067.200,"methodology":"fee schedule"}]}]},{"description":"CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"125","type":"RC"},{"code":"848","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s) ","code_information":[{"code":"30468","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3050.750,"maximum":13376.310,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":3589.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9612.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12003.080,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12003.080,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12715.130,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13376.310,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":3050.750,"methodology":"fee schedule"}]}]},{"description":"Cytopathology, slides, cervical or vaginal; with manual screening and rescreening under physician supervision ","code_information":[{"code":"88153","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.990,"maximum":87.780,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":24.230,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":21.810,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":24.030,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":25.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":55.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":67.040,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":67.040,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":71.370,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":24.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":24.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":24.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":75.450,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":65.600,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":74.510,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":87.780,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":24.030,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":24.030,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":24.030,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":24.030,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":24.030,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":47.580,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":20.800,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":48.060,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":58.390,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":24.030,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":24.030,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":24.030,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":24.030,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":24.030,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":24.030,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":26.190,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":22.210,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":58.390,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":22.210,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":22.210,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":22.210,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":50.460,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":56.470,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":25.230,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":25.230,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":25.470,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":25.470,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":25.470,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":25.470,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":25.470,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":25.230,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":37.250,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":25.230,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":25.230,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":25.230,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":19.990,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":26.010,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":24.030,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":24.510,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":28.840,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":23.550,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY NEOPLASMS WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"141","type":"RC"},{"code":"182","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC 4 Day Stay","code_information":[{"code":"139","type":"RC"},{"code":"438","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Colectomy, partial; abdominal and transanal approach ","code_information":[{"code":"360","type":"RC"},{"code":"44147","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":26278.550,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":19170.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":23394.820,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":23394.820,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":24836.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26278.550,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS 4 Day Stay","code_information":[{"code":"019","type":"MS-DRG"},{"code":"159","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Aortography, abdominal, by serialography, radiological supervision and interpretation ","code_information":[{"code":"619","type":"RC"},{"code":"75625","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":128.830,"maximum":128.830,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":128.830,"methodology":"fee schedule"}]}]},{"description":"Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia) ","code_information":[{"code":"361","type":"RC"},{"code":"65730","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12635.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1935.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":7216.640,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":9011.260,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":9011.260,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":9545.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10042.210,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7577.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8586.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":10131.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"Superior Health 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","code_information":[{"code":"75833","type":"CPT"},{"code":"922","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":149.950,"maximum":149.950,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":149.950,"methodology":"fee schedule"}]}]},{"description":"PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (eg, promyelocytic leukemia) translocation analysis; single breakpoint (eg, intron 3, intron 6 or exon 6), qualitative o ","code_information":[{"code":"81316","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":177.620,"maximum":207.310,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":207.310,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":177.620,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC 3 Day 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"}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS 4 Day Stay","code_information":[{"code":"065","type":"MS-DRG"},{"code":"158","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure ","code_information":[{"code":"302","type":"RC"},{"code":"88344","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":291.260,"maximum":476.720,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":476.720,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":476.720,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":291.260,"methodology":"fee schedule"}]}]},{"description":"EXTRAOCULAR PROCEDURES EXCEPT ORBIT ","code_information":[{"code":"115","type":"MS-DRG"},{"code":"122","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC Pediatric","code_information":[{"code":"113","type":"RC"},{"code":"729","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16966.000,"maximum":22685.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":16966.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":19224.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22685.000,"methodology":"case rate"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC 2 Day Stay","code_information":[{"code":"134","type":"RC"},{"code":"896","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC 3 Day Stay","code_information":[{"code":"139","type":"RC"},{"code":"418","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm ","code_information":[{"code":"12002","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":330.240,"maximum":5841.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":330.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":412.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":412.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":436.820,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":459.540,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"COMPLICATED PEPTIC ULCER WITH CC ","code_information":[{"code":"381","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5984.880,"maximum":5984.880,"payers_information":[{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":5984.880,"methodology":"fee schedule"}]}]},{"description":"Urography, infusion, drip technique and/or bolus technique; ","code_information":[{"code":"11750","type":"CDM"},{"code":"74410","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":140.580,"maximum":1361.880,"gross_charge":3054.74,"discounted_cash":3054.74,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":153.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":221.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":289.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":289.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":327.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":365.650,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":1018.180,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":1153.720,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1361.880,"methodology":"fee schedule"},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":146.260,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":156.200,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":156.200,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":156.200,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":156.200,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":140.580,"methodology":"fee schedule"}]}]},{"description":"Trypsin; feces, quantitative, 24-hour collection ","code_information":[{"code":"84490","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8.510,"maximum":9.930,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9.930,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":8.510,"methodology":"fee schedule"}]}]},{"description":"Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report ","code_information":[{"code":"615","type":"RC"},{"code":"91112","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":825.790,"maximum":825.790,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":825.790,"methodology":"fee schedule"}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"096","type":"MS-DRG"},{"code":"131","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITH MCC 2 Day Stay","code_information":[{"code":"153","type":"RC"},{"code":"193","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"HIV WITH OR WITHOUT OTHER RELATED CONDITION ","code_information":[{"code":"130","type":"RC"},{"code":"977","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS ","code_information":[{"code":"124","type":"RC"},{"code":"870","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Esophagoscopy, flexible, transoral; with injection sclerosis of esophageal varices ","code_information":[{"code":"43204","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":606.240,"maximum":5055.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2943.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3675.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3675.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3893.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4095.960,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":606.240,"methodology":"fee schedule"}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"130","type":"RC"},{"code":"301","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC ","code_information":[{"code":"118","type":"RC"},{"code":"284","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC 4 Day Stay","code_information":[{"code":"128","type":"RC"},{"code":"488","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"MAJOR CHEST TRAUMA WITH CC ","code_information":[{"code":"121","type":"RC"},{"code":"184","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"Operative ablation of supraventricular arrhythmogenic focus or pathway (eg, Wolff-Parkinson-White, atrioventricular node re-entry), tract(s) and/or focus (foci); without cardiopulmonary bypass ","code_information":[{"code":"33250","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":19488.550,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":14217.300,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":17349.930,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":17349.930,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":18419.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":19488.550,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, direct probe technique ","code_information":[{"code":"305","type":"RC"},{"code":"87520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.740,"maximum":88.040,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":88.040,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":88.040,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":31.220,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":26.740,"methodology":"fee schedule"}]}]},{"description":"CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC 4 Day Stay","code_information":[{"code":"154","type":"RC"},{"code":"275","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Lutetium lu 177 vipivotide tetraxetan, therapeutic, 1 millicurie ","code_information":[{"code":"891","type":"RC"},{"code":"A9607","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":427.880,"maximum":427.880,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":427.880,"methodology":"fee schedule"}]}]},{"description":"Closure of enterostomy, large or small intestine; with resection and colorectal anastomosis (eg, closure of Hartmann type procedure) ","code_information":[{"code":"44626","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":21652.500,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":15795.950,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":19276.420,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":19276.420,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":20464.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":21652.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"PLCG2 (phospholipase C gamma 2) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, R665W, S707F, L845F) ","code_information":[{"code":"309","type":"RC"},{"code":"81320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":291.360,"maximum":291.360,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":291.360,"methodology":"fee schedule"}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITHOUT MCC ","code_information":[{"code":"081","type":"MS-DRG"},{"code":"119","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Excision or curettage of bone cyst or benign tumor, humerus; with autograft (includes obtaining graft) ","code_information":[{"code":"24115","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":482.000,"maximum":4100.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":4100.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3162.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3162.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3004.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":3720.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2176.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":2470.480,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2638.370,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":2638.370,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":2638.370,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":2638.370,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":2374.530,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":482.000,"methodology":"case rate"}]}]},{"description":"Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; each additional gestation (List ","code_information":[{"code":"349","type":"RC"},{"code":"76810","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":90.320,"maximum":284.120,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":284.120,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":284.120,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":90.320,"methodology":"fee schedule"}]}]},{"description":"Reconstruction of complex cardiac anomaly (eg, single ventricle or hypoplastic left heart) with palliation of single ventricle with aortic outflow obstruction and aortic arch hypoplasia, creation of c ","code_information":[{"code":"33622","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Erythropoietin ","code_information":[{"code":"82668","type":"CPT"},{"code":"826680","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15.620,"maximum":68.620,"gross_charge":519.24,"discounted_cash":519.24,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":18.950,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":17.040,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":18.790,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":19.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":43.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":52.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":52.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":55.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":18.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":18.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":18.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":59.000,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":51.280,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":58.240,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":68.620,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":18.790,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":18.790,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":18.790,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":18.790,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":18.790,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":37.200,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":16.250,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":37.580,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":56.380,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":18.790,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":18.790,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":18.790,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":18.790,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":18.790,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":18.790,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":20.480,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":17.360,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":45.660,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":17.360,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":17.360,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":17.360,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":39.460,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":44.160,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":19.730,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":19.730,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":19.920,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":19.920,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":19.920,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":19.920,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":19.920,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":19.730,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":29.120,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":19.730,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":19.730,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":19.730,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":15.620,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":20.340,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":18.790,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":19.170,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":22.550,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":18.410,"methodology":"fee schedule"}]}]},{"description":"OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC 2 Day Stay","code_information":[{"code":"117","type":"RC"},{"code":"167","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC Pediatric","code_information":[{"code":"027","type":"MS-DRG"},{"code":"113","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":38607.000,"maximum":51623.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":38607.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":43748.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":51623.000,"methodology":"case rate"}]}]},{"description":"SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY ","code_information":[{"code":"132","type":"RC"},{"code":"450","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY 2 Day Stay","code_information":[{"code":"122","type":"RC"},{"code":"895","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"TRAUMATIC INJURY WITHOUT MCC ","code_information":[{"code":"157","type":"RC"},{"code":"914","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Injection, hyaluronidase, recombinant, 1 usp unit ","drug_information":{"unit":1.500000000000000e+002,"type":"UN"},"code_information":[{"code":"350706","type":"CDM"},{"code":"636","type":"RC"},{"code":"J3473","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.590,"maximum":0.590,"gross_charge":627.08,"discounted_cash":627.08,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.590,"methodology":"fee schedule"}]}]},{"description":"CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"132","type":"RC"},{"code":"416","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease ºCOVID-19») vaccine, mRNA-LNP, spike protein, 10 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use ","code_information":[{"code":"91319","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":87.780,"maximum":225.950,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_percentage":8.07,"standard_charge_algorithm":"Reimbursement will be 8.07% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":148.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":180.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":180.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":192.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":203.650,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":168.170,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":191.450,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":225.950,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_percentage":15.84,"standard_charge_algorithm":"Reimbursement will be 15.84% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_percentage":16.00,"standard_charge_algorithm":"Reimbursement will be 16% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_percentage":8.72,"standard_charge_algorithm":"Reimbursement will be 8.72% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":19.44,"standard_charge_algorithm":"Reimbursement will be 19.44% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_percentage":16.80,"standard_charge_algorithm":"Reimbursement will be 16.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_percentage":8.48,"standard_charge_algorithm":"Reimbursement will be 8.48% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_percentage":8.48,"standard_charge_algorithm":"Reimbursement will be 8.48% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_percentage":8.48,"standard_charge_algorithm":"Reimbursement will be 8.48% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_percentage":8.48,"standard_charge_algorithm":"Reimbursement will be 8.48% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_percentage":8.48,"standard_charge_algorithm":"Reimbursement will be 8.48% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior","plan_name":"HIX","standard_charge_percentage":12.40,"standard_charge_algorithm":"Reimbursement will be 12.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":87.780,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_percentage":8.16,"standard_charge_algorithm":"Reimbursement will be 8.16% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_percentage":9.60,"standard_charge_algorithm":"Reimbursement will be 9.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_percentage":7.84,"standard_charge_algorithm":"Reimbursement will be 7.84% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Arthrotomy, with biopsy; hip joint ","code_information":[{"code":"27052","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":636.360,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2561.690,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3198.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3198.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3388.480,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3564.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":636.360,"methodology":"fee schedule"}]}]},{"description":"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH 2 Day Stay","code_information":[{"code":"116","type":"RC"},{"code":"618","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"072","type":"MS-DRG"},{"code":"111","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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"}]}]},{"description":"RENAL FAILURE WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"118","type":"RC"},{"code":"684","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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"}]}]},{"description":"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"153","type":"RC"},{"code":"585","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH CC ","code_information":[{"code":"0D1A87B","type":"ICD"},{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2950.000,"maximum":2950.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2950.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC ","code_information":[{"code":"251","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1275.000,"maximum":3025.000,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":1275.000,"methodology":"per diem","additional_payer_notes":"Days 2+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3025.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"135","type":"RC"},{"code":"738","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT 4 Day Stay","code_information":[{"code":"008","type":"MS-DRG"},{"code":"152","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC ","code_information":[{"code":"133","type":"RC"},{"code":"167","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC ","code_information":[{"code":"917","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.000,"maximum":26551.720,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":16907.450,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_dollar":13174.560,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_dollar":16468.200,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":17130.140,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":17986.650,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Averde Health","plan_name":"COMM","standard_charge_percentage":33.00,"standard_charge_algorithm":"Reimbursement will be 33% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":19551.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":24588.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":24588.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":24862.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":17130.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":17130.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":17130.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25134.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":16958.840,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":16958.840,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":16958.840,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":16958.840,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":16958.840,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":24251.140,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":21405.520,"methodology":"fee schedule"},{"payer_name":"First Health","plan_name":"Exclusive","standard_charge_dollar":2258.000,"methodology":"per diem"},{"payer_name":"First Health","plan_name":"NonExclusive","standard_charge_dollar":2346.000,"methodology":"per diem"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":24496.100,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":62.00,"standard_charge_algorithm":"Reimbursement will be 62% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"SOUTHTEXASISDRATES","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":16359.280,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":23786.350,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":16359.280,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":16359.280,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":16359.280,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":16359.280,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":23786.350,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":21855.650,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":18671.850,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":24854.430,"methodology":"fee schedule"},{"payer_name":"MultiPlan","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":25720.910,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":19526.580,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":17986.650,"methodology":"fee schedule"},{"payer_name":"PPO Next/ Medical Control","plan_name":"COMMPPO","standard_charge_percentage":75.00,"standard_charge_algorithm":"Reimbursement will be 75% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":17986.650,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":17472.740,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":17472.740,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":17472.740,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":17472.740,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":17472.740,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":18329.250,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":26551.720,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":17986.650,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":17986.650,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":17986.650,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.000,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.000,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":17130.140,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":17986.650,"methodology":"fee schedule"},{"payer_name":"Texas Workforce Commission","plan_name":"WORKERSCOMP","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":17130.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6450.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $552131.00, reimbursement will be $6139 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalBenefitPlan","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16941.710,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":16.10,"standard_charge_algorithm":"Reimbursement will be 16.1% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":18500.550,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":17198.660,"methodology":"fee schedule"}]}]},{"description":"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"158","type":"RC"},{"code":"585","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS Pediatric","code_information":[{"code":"065","type":"MS-DRG"},{"code":"203","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":22422.000,"maximum":29980.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":22422.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":25407.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":29980.000,"methodology":"case rate"}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC ","code_information":[{"code":"121","type":"RC"},{"code":"282","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration, inc ","code_information":[{"code":"34710","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":12018.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":7906.470,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":9648.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":9648.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":10243.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10837.900,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Microlyte matrix, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"892","type":"RC"},{"code":"A2005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"Excision of benign tumor or cyst of mandible, by enucleation and/or curettage ","code_information":[{"code":"21040","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4950.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6181.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6181.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6548.230,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6888.730,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"Superior Health 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PROCEDURES FOR INJURIES WITH MCC ","code_information":[{"code":"144","type":"RC"},{"code":"907","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"Gastrorrhaphy, suture of perforated duodenal or gastric ulcer, wound, or injury ","code_information":[{"code":"43840","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":18392.660,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":13417.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":16374.300,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":16374.300,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":17383.480,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":18392.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"}]}]},{"description":"KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC 4 Day Stay","code_information":[{"code":"133","type":"RC"},{"code":"650","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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"}]}]},{"description":"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC ","code_information":[{"code":"153","type":"RC"},{"code":"723","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC ","code_information":[{"code":"169","type":"RC"},{"code":"192","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Cystography, minimum of 3 views, radiological supervision and interpretation ","code_information":[{"code":"74430","type":"CPT"},{"code":"920","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":42.270,"maximum":42.270,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":42.270,"methodology":"fee schedule"}]}]},{"description":"HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC 4 Day Stay","code_information":[{"code":"111","type":"RC"},{"code":"420","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":23258.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":24609.030,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health 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"}]}]},{"description":"Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions ","code_information":[{"code":"17110","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":330.240,"maximum":5841.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":330.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":412.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":412.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":436.820,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":459.540,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH MCC 3 Day Stay","code_information":[{"code":"120","type":"RC"},{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"DIABETES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"153","type":"RC"},{"code":"639","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Laparoscopy, surgical; jejunostomy (eg, for decompression or feeding) ","code_information":[{"code":"369","type":"RC"},{"code":"44186","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":15581.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9135.710,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11407.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11407.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12084.270,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12712.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7367.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8349.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9124.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"}]}]},{"description":"PNEUMOTHORAX WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"127","type":"RC"},{"code":"201","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"OTHER VASCULAR PROCEDURES WITH CC 3 Day Stay","code_information":[{"code":"117","type":"RC"},{"code":"253","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"OSTEOMYELITIS WITH CC ","code_information":[{"code":"100","type":"RC"},{"code":"540","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH 4 Day Stay","code_information":[{"code":"003","type":"MS-DRG"},{"code":"139","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Percutaneous transluminal angioplasty of native or recurrent coarctation of the aorta ","code_information":[{"code":"33897","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":12018.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5739.330,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7003.930,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7003.930,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7435.600,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7867.260,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Culture, typing; identification by nucleic acid (DNA or RNA) probe, direct probe technique, per culture or isolate, each organism probed ","code_information":[{"code":"87149","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.670,"maximum":73.230,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":20.220,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":18.190,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":21.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":45.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":55.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":55.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":59.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":62.960,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":54.730,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":62.150,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":73.230,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":39.700,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":17.350,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":40.100,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":60.170,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":21.850,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":18.520,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":48.720,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":18.520,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":18.520,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":18.520,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":42.110,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":47.120,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":21.050,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":21.050,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":21.250,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":21.250,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":21.250,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":21.250,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":21.250,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":21.050,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":31.080,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":21.050,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":21.050,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":21.050,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":16.670,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":21.700,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":20.450,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":24.060,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":19.650,"methodology":"fee schedule"}]}]},{"description":"Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure) ","code_information":[{"code":"360","type":"RC"},{"code":"69990","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":5841.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of a ","code_information":[{"code":"33965","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12018.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1830.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":2233.610,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":2233.610,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":2371.270,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2508.940,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"MAJOR SKIN DISORDERS WITH MCC ","code_information":[{"code":"151","type":"RC"},{"code":"595","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC 2 Day Stay","code_information":[{"code":"157","type":"RC"},{"code":"832","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"CHOLECYSTECTOMY WITH C.D.E. WITH MCC ","code_information":[{"code":"148","type":"RC"},{"code":"411","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"DESTR PARAVERTEBRAL N ADD-ON ","code_information":[{"code":"481","type":"RC"},{"code":"64627","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WIT ","code_information":[{"code":"115","type":"RC"},{"code":"496","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Antibody; Giardia lamblia ","code_information":[{"code":"319","type":"RC"},{"code":"86674","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.610,"maximum":51.240,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":51.240,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":51.240,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":12.610,"methodology":"fee schedule"}]}]},{"description":"Cranioplasty for skull defect; larger than 5 cm diameter ","code_information":[{"code":"481","type":"RC"},{"code":"62141","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":15478.050,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11291.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":13779.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":13779.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14628.790,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15478.050,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC ","code_information":[{"code":"970","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17212.620,"maximum":17212.620,"payers_information":[{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":17212.620,"methodology":"fee schedule"}]}]},{"description":"Iron stain, peripheral blood ","code_information":[{"code":"302","type":"RC"},{"code":"85536","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.900,"maximum":22.500,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":22.500,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":22.500,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6.880,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":5.900,"methodology":"fee schedule"}]}]},{"description":"COMPLICATED PEPTIC ULCER WITH CC 2 Day Stay","code_information":[{"code":"152","type":"RC"},{"code":"381","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"WOUND DEBRIDEMENTS FOR INJURIES WITH CC 3 Day Stay","code_information":[{"code":"144","type":"RC"},{"code":"902","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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"}]}]},{"description":"Radiologic examination, sinuses, paranasal, less than 3 views ","code_information":[{"code":"611","type":"RC"},{"code":"70210","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":33.060,"maximum":33.060,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":33.060,"methodology":"fee schedule"}]}]},{"description":"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC Pediatric","code_information":[{"code":"143","type":"RC"},{"code":"272","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":27605.000,"maximum":36910.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":27605.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":31280.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36910.000,"methodology":"case rate"}]}]},{"description":"CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC ","code_information":[{"code":"101","type":"RC"},{"code":"260","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC ","code_information":[{"code":"149","type":"RC"},{"code":"298","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Enucleation of eye; with implant, muscles not attached to implant ","code_information":[{"code":"65103","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15410.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5910.140,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7379.860,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7379.860,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7817.650,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8224.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1184.020,"methodology":"fee schedule"}]}]},{"description":"TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"084","type":"MS-DRG"},{"code":"152","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; respiratory syncytial virus ","code_information":[{"code":"319","type":"RC"},{"code":"87280","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.500,"maximum":41.740,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":41.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":41.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":11.500,"methodology":"fee schedule"}]}]},{"description":"URETHRAL PROCEDURES WITH CC/MCC 3 Day Stay","code_information":[{"code":"156","type":"RC"},{"code":"671","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT 3 Day Stay","code_information":[{"code":"100","type":"RC"},{"code":"470","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Choledochotomy or choledochostomy with exploration, drainage, or removal of calculus, with or without cholecystotomy; with transduodenal sphincterotomy or sphincteroplasty ","code_information":[{"code":"47425","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":18518.560,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":13509.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":16486.390,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":16486.390,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":17502.480,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":18518.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC 3 Day Stay","code_information":[{"code":"148","type":"RC"},{"code":"177","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension support ","code_information":[{"code":"E2630","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":798.520,"maximum":1980.010,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":821.750,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":814.820,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":855.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":814.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":814.820,"methodology":"fee 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"}]}]},{"description":"Lymphangiography, extremity only, bilateral, radiological supervision and interpretation ","code_information":[{"code":"612","type":"RC"},{"code":"75803","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":305.590,"maximum":305.590,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":305.590,"methodology":"fee schedule"}]}]},{"description":"Release of extensive scar tissue without detaching extraocular muscle (separate procedure) ","code_information":[{"code":"499","type":"RC"},{"code":"67343","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":749.300,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3657.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":4567.070,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":4567.070,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":4838.000,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5089.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7577.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8586.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":10131.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":285.280,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":256.630,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":297.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":647.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":789.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":789.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":840.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":888.240,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":772.250,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":877.060,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1033.350,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":560.100,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":244.750,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":565.760,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":308.340,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":261.380,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":687.400,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":261.380,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":261.380,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":261.380,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":594.050,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":664.770,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":297.020,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":297.020,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":299.850,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":299.850,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":299.850,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":299.850,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":299.850,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":297.020,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":438.460,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":297.020,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":297.020,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":297.020,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":235.240,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":288.540,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":339.460,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":277.220,"methodology":"fee schedule"}]}]},{"description":"KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC 2 Day Stay","code_information":[{"code":"158","type":"RC"},{"code":"651","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"132","type":"RC"},{"code":"331","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Synovectomy, tendon sheath, foot; flexor ","code_information":[{"code":"28086","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified ","code_information":[{"code":"636","type":"RC"},{"code":"J7192","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2.620,"maximum":2.620,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2.620,"methodology":"fee schedule"}]}]},{"description":"Thyrotropin releasing hormone (TRH) stimulation panel; 1 hour This panel must include the following: Thyroid stimulating hormone (TSH) (84443 x 3) ","code_information":[{"code":"312","type":"RC"},{"code":"80438","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":43.190,"maximum":175.520,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":175.520,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":175.520,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":43.190,"methodology":"fee schedule"}]}]},{"description":"CERVICAL SPINAL FUSION WITH MCC ","code_information":[{"code":"131","type":"RC"},{"code":"471","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Echocardiography, transesophageal (TEE) for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing (continuous) assessment of ( ","code_information":[{"code":"619","type":"RC"},{"code":"93318","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":254.250,"maximum":254.250,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":254.250,"methodology":"fee schedule"}]}]},{"description":"INFLAMMATORY BOWEL DISEASE WITH MCC 4 Day Stay","code_information":[{"code":"128","type":"RC"},{"code":"385","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"OTHER VASCULAR PROCEDURES WITH MCC ","code_information":[{"code":"148","type":"RC"},{"code":"252","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC ","code_information":[{"code":"110","type":"RC"},{"code":"438","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Closure of salivary fistula ","code_information":[{"code":"369","type":"RC"},{"code":"D7983","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bypass graft, with vein; ilioiliac ","code_information":[{"code":"35563","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":17814.370,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":12995.950,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":15859.470,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":15859.470,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":16836.920,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17814.370,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC 4 Day Stay","code_information":[{"code":"153","type":"RC"},{"code":"241","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Excision of lacrimal sac (dacryocystectomy) ","code_information":[{"code":"362","type":"RC"},{"code":"68520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MEDICAL BACK PROBLEMS WITH MCC 4 Day Stay","code_information":[{"code":"131","type":"RC"},{"code":"551","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, when performed; without intercondylar extension ","code_information":[{"code":"24545","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":595.000,"maximum":7467.810,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5069.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3911.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3911.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3716.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4601.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2692.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":6992.590,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":7467.810,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":7467.810,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":7467.810,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":7467.810,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":6721.030,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":595.000,"methodology":"case rate"}]}]},{"description":"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"132","type":"RC"},{"code":"407","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Clotting inhibitors or anticoagulants; antithrombin III, activity ","code_information":[{"code":"85300","type":"CPT"},{"code":"853001","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":9.850,"maximum":43.270,"gross_charge":1864.96,"discounted_cash":1864.96,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":11.950,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":10.750,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":11.850,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":12.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":27.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":33.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":33.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":35.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":11.850,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":11.850,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":11.850,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":37.210,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":32.340,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":36.730,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":43.270,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":11.850,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":11.850,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":11.850,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":11.850,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":11.850,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":23.460,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":10.250,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":23.700,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":35.550,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":11.850,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":11.850,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":11.850,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":11.850,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":11.850,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11.850,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":12.920,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":10.950,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":28.800,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":10.950,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":10.950,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":10.950,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":24.890,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":27.850,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":12.440,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":12.440,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":12.560,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":12.560,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":12.560,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":12.560,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":12.560,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":12.440,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":18.370,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":12.440,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":12.440,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":12.440,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":9.850,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":12.830,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":11.850,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12.090,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":14.220,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":11.610,"methodology":"fee schedule"}]}]},{"description":"CHOLECYSTECTOMY WITH C.D.E. WITH MCC ","code_information":[{"code":"152","type":"RC"},{"code":"411","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"REVISION OF HIP OR KNEE REPLACEMENT WITH CC ","code_information":[{"code":"129","type":"RC"},{"code":"467","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Removal of a permanent cardiac contractility modulation-defibrillation system component(s); single transvenous pacing lead only ","code_information":[{"code":"0920T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6878.280,"maximum":15410.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":6878.280,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":8588.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":8588.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":9098.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9571.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"}]}]},{"description":"Bile acids; cholylglycine ","code_information":[{"code":"311","type":"RC"},{"code":"82240","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.780,"maximum":92.520,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":92.520,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":92.520,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":22.780,"methodology":"fee schedule"}]}]},{"description":"TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC 3 Day Stay","code_information":[{"code":"085","type":"MS-DRG"},{"code":"116","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC ","code_information":[{"code":"140","type":"RC"},{"code":"842","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"ATHEROSCLEROSIS WITHOUT MCC 4 Day Stay","code_information":[{"code":"159","type":"RC"},{"code":"303","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC 2 Day Stay","code_information":[{"code":"155","type":"RC"},{"code":"576","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH CC ","code_information":[{"code":"113","type":"RC"},{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; with osteotomy (eg, flatfoot correction) ","code_information":[{"code":"28735","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":31298.870,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":22492.340,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":28085.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":28085.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":29751.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":31298.870,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9124.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":8053.900,"methodology":"fee schedule"}]}]},{"description":"OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC ","code_information":[{"code":"127","type":"RC"},{"code":"394","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH 2 Day Stay","code_information":[{"code":"140","type":"RC"},{"code":"542","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Transcatheter placement of intravascular stent(s), central dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision and interpretation required to perfo ","code_information":[{"code":"36908","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Osteotomy; talus High Cost Surgery","code_information":[{"code":"28302","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2369.000,"maximum":2369.000,"payers_information":[{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":2369.000,"methodology":"case rate"}]}]},{"description":"Stimulants, synthetic ","code_information":[{"code":"314","type":"RC"},{"code":"80371","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.050,"maximum":37.140,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":37.140,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":37.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":12.050,"methodology":"fee schedule"}]}]},{"description":"Skin test; tuberculosis, intradermal ","code_information":[{"code":"307","type":"RC"},{"code":"86580","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.770,"maximum":24.670,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":21.770,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":21.770,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":24.670,"methodology":"fee schedule"}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITH MCC ","code_information":[{"code":"157","type":"RC"},{"code":"388","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"INJECTION(S) SPIDER VEINS ","code_information":[{"code":"361","type":"RC"},{"code":"36469","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC ","code_information":[{"code":"126","type":"RC"},{"code":"841","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace, lumbar; each additional interspace (List se High Cost Surgery","code_information":[{"code":"22632","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2369.000,"maximum":2369.000,"payers_information":[{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":2369.000,"methodology":"case rate"}]}]},{"description":"Fresh frozen plasma, thawing, each unit ","code_information":[{"code":"307","type":"RC"},{"code":"86927","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":55.240,"maximum":149.160,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":55.240,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":55.240,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":149.160,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, knee; 3 views ","code_information":[{"code":"352","type":"RC"},{"code":"73562","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":41.580,"maximum":41.580,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":41.580,"methodology":"fee schedule"}]}]},{"description":"Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; unilateral or bilateral bone marrow h ","code_information":[{"code":"0265T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":7216.700,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":9011.330,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":9011.330,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":9545.900,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10042.290,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"}]}]},{"description":"SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS 3 Day Stay","code_information":[{"code":"019","type":"MS-DRG"},{"code":"120","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS 3 Day Stay","code_information":[{"code":"029","type":"MS-DRG"},{"code":"133","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Extraction (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules) ","code_information":[{"code":"10040","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"141","type":"RC"},{"code":"148","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Repair of complex cardiac anomalies (eg, single ventricle) by modified Fontan procedure ","code_information":[{"code":"33617","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":28549.650,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":20827.570,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":25416.690,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":25416.690,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":26983.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":28549.650,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC ","code_information":[{"code":"137","type":"RC"},{"code":"557","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC 2 Day Stay","code_information":[{"code":"169","type":"RC"},{"code":"256","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC ","code_information":[{"code":"115","type":"RC"},{"code":"489","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC 4 Day Stay","code_information":[{"code":"121","type":"RC"},{"code":"258","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC 4 Day Stay","code_information":[{"code":"101","type":"RC"},{"code":"154","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Gastrointestinal endoscopic ultrasound, supervision and interpretation ","code_information":[{"code":"402","type":"RC"},{"code":"76975","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":112.550,"maximum":517.790,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":340.350,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":340.350,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":517.790,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":112.550,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of post hip arthroplasty dislocation; without anesthesia ","code_information":[{"code":"27265","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":91.560,"maximum":5055.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":407.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":508.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":508.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":539.100,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":567.130,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":91.560,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC ","code_information":[{"code":"10D07Z7","type":"ICD"},{"code":"130","type":"RC"},{"code":"806","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1422.000,"maximum":2678.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":2678.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1964.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":2433.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1422.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "}]}]},{"description":"Radiologic examination, pelvis; complete, minimum of 3 views ","code_information":[{"code":"404","type":"RC"},{"code":"72190","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":43.290,"maximum":43.290,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":43.290,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, ankle, surgical, excision of osteochondral defect of talus and/or tibia, including drilling of the defect ","code_information":[{"code":"29891","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with removal of lesion ","code_information":[{"code":"369","type":"RC"},{"code":"67420","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1184.020,"maximum":15410.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1392.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5910.140,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7379.860,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7379.860,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7817.650,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8224.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7367.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8349.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1184.020,"methodology":"fee schedule"}]}]},{"description":"MAJOR CHEST TRAUMA WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"154","type":"RC"},{"code":"185","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) ","code_information":[{"code":"409","type":"RC"},{"code":"93990","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":111.150,"maximum":111.150,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":111.150,"methodology":"fee schedule"}]}]},{"description":"Laryngoscopy direct, with or without tracheoscopy; diagnostic, except newborn ","code_information":[{"code":"31525","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":564.110,"maximum":5055.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2703.850,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3376.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3376.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3576.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3762.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":564.110,"methodology":"fee schedule"}]}]},{"description":"Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck ","code_information":[{"code":"51715","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1675.750,"maximum":15410.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5705.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7123.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7123.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7546.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7938.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1675.750,"methodology":"fee schedule"}]}]},{"description":"Excision of skin and subcutaneous tissue for hidradenitis, axillary; with complex repair ","code_information":[{"code":"11451","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":422.000,"maximum":3589.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3589.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2768.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2768.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":2630.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":3257.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1904.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":839.660,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":896.720,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":896.720,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":896.720,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":896.720,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":807.050,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":422.000,"methodology":"case rate"}]}]},{"description":"Chemical cauterization of granulation tissue (ie, proud flesh) ","code_information":[{"code":"17250","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":330.240,"maximum":5841.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":330.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":412.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":412.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":436.820,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":459.540,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; 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may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14954.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15732.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":9999.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm ","code_information":[{"code":"15836","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":7037.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4382.700,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":5472.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":5472.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":5797.220,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6098.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative 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"}]}]},{"description":"Albumin; ischemia modified ","code_information":[{"code":"310","type":"RC"},{"code":"82045","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":29.080,"maximum":118.160,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":118.160,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":118.160,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":29.080,"methodology":"fee schedule"}]}]},{"description":"LAPAROSCOPY, SURGICAL, REPAIR, VENTRAL, UMBILICAL, SPIGELIAN OR EPIGASTRIC HERNIA (INCLUDES MESH INSERTION, WHEN PERFORMED); REDUCIBLE ","code_information":[{"code":"481","type":"RC"},{"code":"49652","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":11460.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9124.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"}]}]},{"description":"VEIN LIGATION AND STRIPPING ","code_information":[{"code":"123","type":"RC"},{"code":"263","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Carpectomy; all bones of proximal row ","code_information":[{"code":"25215","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":8444.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"VIRAL MENINGITIS WITH CC/MCC ","code_information":[{"code":"075","type":"MS-DRG"},{"code":"156","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"ATHEROSCLEROSIS WITH MCC 2 Day Stay","code_information":[{"code":"101","type":"RC"},{"code":"302","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Thyroid uptake, single or multiple quantitative measurement(s) (including stimulation, suppression, or discharge, when performed) ","code_information":[{"code":"739","type":"RC"},{"code":"78012","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":82.480,"maximum":82.480,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":82.480,"methodology":"fee schedule"}]}]},{"description":"PMS2 (postmeiotic segregation increased 2 ºS. cerevisiae») (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants ","code_information":[{"code":"309","type":"RC"},{"code":"81319","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":174.360,"maximum":573.870,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":573.870,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":573.870,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":203.500,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":174.360,"methodology":"fee schedule"}]}]},{"description":"OTHER O.R. PROCEDURES FOR INJURIES WITH MCC 3 Day Stay","code_information":[{"code":"137","type":"RC"},{"code":"907","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC ","code_information":[{"code":"131","type":"RC"},{"code":"959","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC ","code_information":[{"code":"112","type":"RC"},{"code":"324","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure ","code_information":[{"code":"319","type":"RC"},{"code":"88342","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":149.160,"maximum":299.170,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":299.170,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":299.170,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":149.160,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS 3 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"207","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"128","type":"RC"},{"code":"520","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Correction, cock-up fifth toe, with plastic skin closure (eg, Ruiz-Mora type procedure) ","code_information":[{"code":"28286","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"136","type":"RC"},{"code":"905","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"HEADACHES WITHOUT MCC 4 Day Stay","code_information":[{"code":"103","type":"MS-DRG"},{"code":"115","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITHOUT MCC 4 Day Stay","code_information":[{"code":"081","type":"MS-DRG"},{"code":"148","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Oncology (breast ductal carcinoma in situ), protein expression profiling by immunohistochemistry of 7 proteins (COX2, FOXA1, HER2, Ki-67, p16, PR, SIAH2), with 4 clinicpathologic factors, utilizing fo ","code_information":[{"code":"0295U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1897.000,"maximum":1897.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1897.000,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, hip, surgical; with synovectomy ","code_information":[{"code":"29863","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":15581.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance imaging, breast, without contrast material; 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"}]}]},{"description":"CT and CTA without Contra ","code_information":[{"code":"8005","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":217.840,"maximum":540.150,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":224.180,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":222.290,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":233.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":222.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":222.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":222.290,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":222.290,"methodology":"fee 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schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":222.290,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":222.290,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":222.290,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":222.290,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":242.290,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":540.150,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":466.800,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":233.400,"methodology":"fee schedule"},{"payer_name":"Prominence 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schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":233.400,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":233.400,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":233.400,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":222.290,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":226.730,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":266.740,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":217.840,"methodology":"fee schedule"}]}]},{"description":"NEUROLOGICAL EYE DISORDERS ","code_information":[{"code":"123","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.000,"maximum":17045.520,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":10854.150,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_dollar":6708.240,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_dollar":8385.300,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":10997.110,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":11546.970,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Averde Health","plan_name":"COMM","standard_charge_percentage":33.00,"standard_charge_algorithm":"Reimbursement will be 33% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10140.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12752.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12752.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12894.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":10997.110,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":10997.110,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":10997.110,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13035.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":10887.140,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":10887.140,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":10887.140,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":10887.140,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":10887.140,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":15568.610,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":10899.290,"methodology":"fee schedule"},{"payer_name":"First Health","plan_name":"Exclusive","standard_charge_dollar":2258.000,"methodology":"per diem"},{"payer_name":"First Health","plan_name":"NonExclusive","standard_charge_dollar":2346.000,"methodology":"per diem"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":15725.870,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":62.00,"standard_charge_algorithm":"Reimbursement will be 62% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"SOUTHTEXASISDRATES","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":10502.240,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12111.570,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":10502.240,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":10502.240,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":10502.240,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":10502.240,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12111.570,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11128.490,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":11986.850,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":12655.410,"methodology":"fee schedule"},{"payer_name":"MultiPlan","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":16512.160,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9942.570,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":11546.970,"methodology":"fee schedule"},{"payer_name":"PPO Next/ Medical Control","plan_name":"COMMPPO","standard_charge_percentage":75.00,"standard_charge_algorithm":"Reimbursement will be 75% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":11546.970,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":11217.050,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":11217.050,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":11217.050,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":11217.050,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":11217.050,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":11766.910,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":17045.520,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":11546.970,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":11546.970,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":11546.970,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.000,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.000,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":10997.110,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":11546.970,"methodology":"fee schedule"},{"payer_name":"Texas Workforce Commission","plan_name":"WORKERSCOMP","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":10997.110,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6450.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $552131.00, reimbursement will be $6139 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalBenefitPlan","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":10876.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":16.10,"standard_charge_algorithm":"Reimbursement will be 16.1% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":11876.880,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":11041.100,"methodology":"fee schedule"}]}]},{"description":"Rem odontogen cyst > 1.25 cm ","code_information":[{"code":"362","type":"RC"},{"code":"D7451","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal or bivalving; gauntlet, boot or body cast ","code_information":[{"code":"29700","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":33.860,"maximum":5841.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":240.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":293.450,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":293.450,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":311.640,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":329.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":33.860,"methodology":"fee schedule"}]}]},{"description":"Open treatment of patellar dislocation, with or without partial or total patellectomy ","code_information":[{"code":"27566","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":5487.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Natural killer (NK) cells, total count ","code_information":[{"code":"307","type":"RC"},{"code":"86357","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":32.320,"maximum":131.360,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":131.360,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":131.360,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":37.730,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":32.320,"methodology":"fee schedule"}]}]},{"description":"CEREB THERM PERFUSION PROBE ","code_information":[{"code":"0077T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"BRONCHITIS AND ASTHMA WITHOUT CC/MCC ","code_information":[{"code":"143","type":"RC"},{"code":"203","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"RESPIRATORY NEOPLASMS WITH MCC ","code_information":[{"code":"156","type":"RC"},{"code":"180","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC ","code_information":[{"code":"115","type":"RC"},{"code":"429","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Osteotomy, multiple, with realignment on intramedullary rod, femoral shaft (eg, Sofield type procedure) ","code_information":[{"code":"27454","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":17427.330,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":12713.600,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":15514.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":15514.910,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":16471.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17427.330,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"}]}]},{"description":"Rhinoplasty, secondary; minor revision (small amount of nasal tip work) ","code_information":[{"code":"30430","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2096.960,"maximum":12756.890,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9167.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11447.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11447.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12126.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12756.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2096.960,"methodology":"fee schedule"}]}]},{"description":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZA 2 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"216","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"DIGESTIVE MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"152","type":"RC"},{"code":"376","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"VENTRICULAR SHUNT PROCEDURES WITH MCC 3 Day Stay","code_information":[{"code":"031","type":"MS-DRG"},{"code":"127","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Arthrotomy, ankle, including exploration, drainage, or removal of foreign body ","code_information":[{"code":"27610","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":15410.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1373.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"Trypsin; feces, quantitative, 24-hour collection ","code_information":[{"code":"307","type":"RC"},{"code":"84490","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.510,"maximum":28.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":28.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":28.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9.930,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":8.510,"methodology":"fee schedule"}]}]},{"description":"OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC 2 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"957","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"TRANSURETHRAL PROCEDURES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"131","type":"RC"},{"code":"670","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"ACUTE AND SUBACUTE ENDOCARDITIS WITH CC 2 Day Stay","code_information":[{"code":"151","type":"RC"},{"code":"289","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC ","code_information":[{"code":"151","type":"RC"},{"code":"192","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"MAJOR HEAD AND NECK PROCEDURES WITH MCC ","code_information":[{"code":"121","type":"RC"},{"code":"140","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"VEIN LIGATION AND STRIPPING 4 Day Stay","code_information":[{"code":"143","type":"RC"},{"code":"263","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC ","code_information":[{"code":"112","type":"RC"},{"code":"307","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC ","code_information":[{"code":"120","type":"RC"},{"code":"420","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Oncology (colorectal) screening, quantitative real-time target and signal amplification of 8 RNA markers and fecal hemoglobin, algorithm reported as a positive or negative for colorectal cancer risk ","code_information":[{"code":"0421U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":508.870,"maximum":508.870,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":508.870,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, direct probe technique ","code_information":[{"code":"87495","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.980,"maximum":109.700,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":30.290,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":27.250,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":30.030,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":31.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":68.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":83.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":83.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":89.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":30.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":30.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":30.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":94.290,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":81.980,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":93.110,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":109.700,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":30.030,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":30.030,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":30.030,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":30.030,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":30.030,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":59.460,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":25.990,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":60.060,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":72.970,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":30.030,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":30.030,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":30.030,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":30.030,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":30.030,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":30.030,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":32.730,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":27.750,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":72.970,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":27.750,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":27.750,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":27.750,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":63.060,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":70.570,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":31.530,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":31.530,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":31.830,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":31.830,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":31.830,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":31.830,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":31.830,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":31.530,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":46.550,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":31.530,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":31.530,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":31.530,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":24.980,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":32.500,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":30.030,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":30.630,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":36.040,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":29.430,"methodology":"fee schedule"}]}]},{"description":"VENTRICULAR SHUNT PROCEDURES WITH MCC 2 Day Stay","code_information":[{"code":"031","type":"MS-DRG"},{"code":"167","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC ","code_information":[{"code":"113","type":"RC"},{"code":"723","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Neuroplasty; nerve of hand or foot ","code_information":[{"code":"362","type":"RC"},{"code":"64704","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2946.000,"maximum":5055.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PNEUMOTHORAX WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"101","type":"RC"},{"code":"201","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"160","type":"RC"},{"code":"413","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Injection procedure for antegrade nephrostogram and/or ureterogram, complete diagnostic procedure including imaging guidance (eg, ultrasound and fluoroscopy) and all associated radiological supervisio ","code_information":[{"code":"367","type":"RC"},{"code":"50430","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic ","code_information":[{"code":"329","type":"RC"},{"code":"72157","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":341.840,"maximum":1142.970,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1142.970,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1142.970,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":341.840,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, abdomen; 1 view ","code_information":[{"code":"409","type":"RC"},{"code":"74018","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30.680,"maximum":182.030,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":81.530,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":81.530,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":182.030,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":30.680,"methodology":"fee schedule"}]}]},{"description":"MAJOR MULTIPLE TRAUMA WITH BRAIN OR SPINAL CODE IN ","code_information":[{"code":"138","type":"RC"},{"code":"A1804","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":25162.940,"maximum":27427.600,"payers_information":[{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":25162.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":25162.940,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":27427.600,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":26421.080,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":25666.190,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":25666.190,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of 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may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12668.410,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12668.410,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13453.640,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14238.870,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT ","code_information":[{"code":"005","type":"MS-DRG"},{"code":"113","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"Piflufolastat f-18, diagnostic, 1 millicurie ","code_information":[{"code":"892","type":"RC"},{"code":"A9595","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":571.710,"maximum":571.710,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":571.710,"methodology":"fee schedule"}]}]},{"description":"FOOT PROCEDURES WITH CC 2 Day Stay","code_information":[{"code":"112","type":"RC"},{"code":"504","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Injection, belimumab, 10 mg ","code_information":[{"code":"636","type":"RC"},{"code":"J0490","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":94.310,"maximum":94.310,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":94.310,"methodology":"fee schedule"}]}]},{"description":"SOFT TISSUE PROCEDURES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"117","type":"RC"},{"code":"502","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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"}]}]},{"description":"WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC Adult","code_information":[{"code":"903","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":30107.000,"maximum":40256.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":30107.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 20.4% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":34116.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 23.1% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":40256.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 27.3% of billable gross charges instead of the contracted rate."}]}]},{"description":"Excision of chalazion; 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"}]}]},{"description":"Arthroscopically aided treatment of tibial fracture, proximal (plateau); bicondylar, includes internal fixation, when performed (includes arthroscopy) ","code_information":[{"code":"29856","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":31298.870,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":22492.340,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":28085.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":28085.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":29751.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":31298.870,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9124.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":7128.440,"methodology":"fee schedule"}]}]},{"description":"WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE 4 Day Stay","code_information":[{"code":"125","type":"RC"},{"code":"463","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC 2 Day Stay","code_information":[{"code":"139","type":"RC"},{"code":"255","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC ","code_information":[{"code":"134","type":"RC"},{"code":"306","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH CC ","code_information":[{"code":"0DL73CZ","type":"ICD"},{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17541.000,"maximum":33041.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":33041.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":25493.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":25493.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":24223.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":29992.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":17541.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":26065.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"CELLULITIS WITH MCC 4 Day Stay","code_information":[{"code":"151","type":"RC"},{"code":"602","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS 4 Day Stay","code_information":[{"code":"156","type":"RC"},{"code":"870","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Injection, allopurinol sodium, 1 mg ","code_information":[{"code":"J0206","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4.450,"maximum":15.010,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":13.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":13.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14.170,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15.010,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":8.850,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":10.080,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":11.890,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":4.450,"methodology":"fee schedule"}]}]},{"description":"Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm ","code_information":[{"code":"12018","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":79.770,"maximum":5841.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":330.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":412.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":412.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":436.820,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":459.540,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":79.770,"methodology":"fee schedule"}]}]},{"description":"Amputation, thigh, through femur, any level; ","code_information":[{"code":"27590","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":16496.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":7807.820,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":9528.190,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":9528.190,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":10115.430,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10702.670,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":9875.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16496.000,"methodology":"case rate"}]}]},{"description":"Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with open peripheral arterial and venous cannulation (eg, femoral, iliac, axillary vessels) (Li ","code_information":[{"code":"33368","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":12018.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":7389.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":9017.510,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":9017.510,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":9573.280,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10129.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"OTHER CIRCULATORY SYSTEM O.R. PROCEDURES ","code_information":[{"code":"129","type":"RC"},{"code":"264","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary High Cost Surgery","code_information":[{"code":"361","type":"RC"},{"code":"37260","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2369.000,"maximum":2369.000,"payers_information":[{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":2369.000,"methodology":"case rate"}]}]},{"description":"RENAL FAILURE WITH MCC ","code_information":[{"code":"119","type":"RC"},{"code":"682","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"DILATE ESOPHAGUS ","code_information":[{"code":"43456","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC ","code_information":[{"code":"156","type":"RC"},{"code":"658","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"NERVOUS SYSTEM NEOPLASMS WITH MCC 2 Day Stay","code_information":[{"code":"054","type":"MS-DRG"},{"code":"123","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair; aorto-bifemoral prosthesis ","code_information":[{"code":"34832","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":25164.030,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":18357.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":22402.600,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":22402.600,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":23783.310,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25164.030,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Clotting inhibitors or anticoagulants; protein C, activity ","code_information":[{"code":"85303","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":11.860,"maximum":13.840,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.840,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":11.860,"methodology":"fee schedule"}]}]},{"description":"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC 2 Day Stay","code_information":[{"code":"040","type":"MS-DRG"},{"code":"100","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC 4 Day Stay","code_information":[{"code":"133","type":"RC"},{"code":"280","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm2, or each additional 1% of body surface area of infants and children, or part ther ","code_information":[{"code":"0480T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1672.000,"maximum":5055.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"Repair sinus of Valsalva aneurysm, with cardiopulmonary bypass ","code_information":[{"code":"33720","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (eg, macular pucker) High Cost Surgery","code_information":[{"code":"361","type":"RC"},{"code":"67041","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2369.000,"maximum":2369.000,"payers_information":[{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":2369.000,"methodology":"case rate"}]}]},{"description":"PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC 3 Day Stay","code_information":[{"code":"067","type":"MS-DRG"},{"code":"135","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Introduction of needle or intracatheter, carotid or vertebral artery ","code_information":[{"code":"36100","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":5841.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC ","code_information":[{"code":"133","type":"RC"},{"code":"905","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WIT ","code_information":[{"code":"130","type":"RC"},{"code":"563","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Removal of foreign body, upper arm or elbow area; deep (subfascial or intramuscular) ","code_information":[{"code":"24201","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":874.740,"maximum":6098.680,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1029.110,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4382.700,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":5472.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":5472.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":5797.220,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6098.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":874.740,"methodology":"fee schedule"}]}]},{"description":"SKIN ULCERS WITH CC ","code_information":[{"code":"116","type":"RC"},{"code":"593","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; injection into supraspinatus tendon including ultrasound guidance, unilateral ","code_information":[{"code":"0718T","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC 4 Day Stay","code_information":[{"code":"151","type":"RC"},{"code":"918","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Excision of lesion of tongue without closure ","code_information":[{"code":"41110","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":152.690,"maximum":5055.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":970.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1184.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1184.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1257.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1331.060,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":152.690,"methodology":"fee schedule"}]}]},{"description":"Lipoprotein, direct measurement; LDL cholesterol ","code_information":[{"code":"309","type":"RC"},{"code":"83721","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.000,"maximum":33.220,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":33.220,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":33.220,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10.500,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":9.000,"methodology":"fee schedule"}]}]},{"description":"INFLAMMATORY BOWEL DISEASE WITH CC ","code_information":[{"code":"159","type":"RC"},{"code":"386","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETER ","code_information":[{"code":"142","type":"RC"},{"code":"221","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC ","code_information":[{"code":"157","type":"RC"},{"code":"270","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"164","type":"RC"},{"code":"310","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC ","code_information":[{"code":"144","type":"RC"},{"code":"576","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Non-contact laser vap prosta ","code_information":[{"code":"490","type":"RC"},{"code":"C9713","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Application of halo, including removal, cranial, 6 or more pins placed, for thin skull osteology (eg, pediatric patients, hydrocephalus, osteogenesis imperfecta) ","code_information":[{"code":"20664","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":11807.880,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8614.090,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":10512.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":10512.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":11160.000,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11807.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"}]}]},{"description":"KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC 4 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"}]}]},{"description":"Injection, plasminogen, human-tvmh, 1 mg ","code_information":[{"code":"344","type":"RC"},{"code":"J2998","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":57.170,"maximum":57.170,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":57.170,"methodology":"fee schedule"}]}]},{"description":"VEIN LIGATION AND STRIPPING 4 Day Stay","code_information":[{"code":"122","type":"RC"},{"code":"263","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES ","code_information":[{"code":"117","type":"RC"},{"code":"845","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Kidney imaging morphology; with vascular flow ","code_information":[{"code":"10417","type":"CDM"},{"code":"78701","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":209.070,"maximum":2751.360,"gross_charge":5261.72,"discounted_cash":5261.72,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":233.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":453.670,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":592.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":592.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":670.470,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":748.760,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2057.000,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":2330.830,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":2751.360,"methodology":"fee schedule"},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":217.520,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":232.300,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":232.300,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":232.300,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":232.300,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":209.070,"methodology":"fee schedule"}]}]},{"description":"PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC ","code_information":[{"code":"101","type":"RC"},{"code":"243","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, and muscle ","code_information":[{"code":"11011","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISOR ","code_information":[{"code":"154","type":"RC"},{"code":"623","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"ORBITAL PROCEDURES WITH CC/MCC 3 Day Stay","code_information":[{"code":"113","type":"MS-DRG"},{"code":"143","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC 2 Day Stay","code_information":[{"code":"152","type":"RC"},{"code":"442","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC ","code_information":[{"code":"120","type":"RC"},{"code":"256","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Injection, bendamustine hcl (bendeka), 1 mg ","code_information":[{"code":"344","type":"RC"},{"code":"J9034","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":21.170,"maximum":21.170,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":21.170,"methodology":"fee schedule"}]}]},{"description":"INSERT CONTRACEPTIVE CAP ","code_information":[{"code":"11975","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"APPENDIX PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"158","type":"RC"},{"code":"399","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Valvuloplasty, mitral valve, with cardiopulmonary bypass; radical reconstruction, with or without ring ","code_information":[{"code":"33427","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":33017.320,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":24086.820,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":29394.090,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":29394.090,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":31205.700,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":33017.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"072","type":"MS-DRG"},{"code":"169","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC ","code_information":[{"code":"117","type":"RC"},{"code":"359","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"OTHER O.R. 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"}]}]},{"description":"Vermilionectomy (lip shave), with mucosal advancement ","code_information":[{"code":"361","type":"RC"},{"code":"40500","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":6888.730,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1119.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4950.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6181.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6181.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6548.230,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6888.730,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":951.370,"methodology":"fee schedule"}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC ","code_information":[{"code":"157","type":"RC"},{"code":"729","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"EXTRACRANIAL PROCEDURES WITH MCC ","code_information":[{"code":"037","type":"MS-DRG"},{"code":"120","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences ","code_information":[{"code":"329","type":"RC"},{"code":"72197","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":360.240,"maximum":1276.330,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1276.330,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1276.330,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":360.240,"methodology":"fee schedule"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; daily management, each day, veno-arterial ","code_information":[{"code":"33949","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HEART FAILURE AND SHOCK WITH MCC 3 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"291","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND CO 2 Day Stay","code_information":[{"code":"115","type":"RC"},{"code":"810","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Radiologic examination, pharynx and/or cervical esophagus, including scout neck radiograph(s) and delayed image(s), when performed, contrast (eg, barium) study ","code_information":[{"code":"730","type":"RC"},{"code":"74210","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":99.510,"maximum":99.510,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":99.510,"methodology":"fee schedule"}]}]},{"description":"Tlso flexible, provides trunk support, extends from sacrococcygeal junction to above t-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on ","code_information":[{"code":"L0454","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":419.930,"maximum":4612.390,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":432.140,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":428.500,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":449.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":428.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":428.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":428.500,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":428.500,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":428.500,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":428.500,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":428.500,"methodology":"fee 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":25.670,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":23.090,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":25.450,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":26.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":58.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":71.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":71.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":75.590,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":25.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":25.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":25.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":79.910,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":69.470,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":78.900,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":92.950,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":25.450,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":25.450,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":25.450,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":25.450,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":25.450,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":50.390,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":22.020,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":50.900,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":76.350,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":25.450,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":25.450,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":25.450,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":25.450,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":25.450,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":25.450,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":27.740,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":23.520,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":61.840,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":23.520,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":23.520,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":23.520,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":53.450,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":59.810,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":26.720,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":26.720,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":26.980,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":26.980,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":26.980,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":26.980,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":26.980,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":26.720,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":39.450,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":26.720,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":26.720,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":26.720,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":21.170,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":27.540,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":25.450,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":25.960,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":30.540,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":24.940,"methodology":"fee schedule"}]}]},{"description":"Oncology (melanoma), gene expression profiling by RTqPCR, PRAME and LINC00518, superficial collection using adhesive patch(es) ","code_information":[{"code":"0089U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":760.000,"maximum":760.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":760.000,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis; 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"}]}]},{"description":"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC 2 Day Stay","code_information":[{"code":"040","type":"MS-DRG"},{"code":"126","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first metatarsal, each ","code_information":[{"code":"28308","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels ","code_information":[{"code":"401","type":"RC"},{"code":"77772","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2790.120,"maximum":2790.120,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":2790.120,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":2790.120,"methodology":"fee schedule"}]}]},{"description":"MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC ","code_information":[{"code":"126","type":"RC"},{"code":"371","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"TRAUMATIC INJURY WITHOUT MCC ","code_information":[{"code":"160","type":"RC"},{"code":"914","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Replacement, complete, of a peripherally inserted central venous access device, with subcutaneous port, through same venous access ","code_information":[{"code":"36585","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":8328.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5237.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6540.220,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6540.220,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6928.200,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7288.470,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5851.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1199.900,"methodology":"fee schedule"}]}]},{"description":"Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 2 to 4 lesions ","code_information":[{"code":"11056","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":330.240,"maximum":5841.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":330.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":412.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":412.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":436.820,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":459.540,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"Revision of ileostomy; complicated (reconstruction in-depth) (separate procedure) ","code_information":[{"code":"44314","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":15410.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9900.110,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12081.480,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12081.480,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12826.090,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13570.700,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"}]}]},{"description":"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC 4 Day Stay","code_information":[{"code":"151","type":"RC"},{"code":"327","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"URETHRAL STRICTURE ","code_information":[{"code":"122","type":"RC"},{"code":"697","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC 4 Day Stay","code_information":[{"code":"146","type":"RC"},{"code":"178","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Whole blood volume determination, including separate measurement of plasma volume and red cell volume (radiopharmaceutical volume-dilution technique) ","code_information":[{"code":"615","type":"RC"},{"code":"78122","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":97.470,"maximum":97.470,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":97.470,"methodology":"fee schedule"}]}]},{"description":"Extensive craniectomy for multiple cranial suture craniosynostosis (eg, cloverleaf skull); not requiring bone grafts ","code_information":[{"code":"480","type":"RC"},{"code":"61558","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC ","code_information":[{"code":"149","type":"RC"},{"code":"577","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"139","type":"RC"},{"code":"148","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"REMOVE CVA DEVICE OBSTRUCT ","code_information":[{"code":"361","type":"RC"},{"code":"36536","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC 2 Day Stay","code_information":[{"code":"020","type":"MS-DRG"},{"code":"127","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Electrical stimulation to aid bone healing; invasive (operative) ","code_information":[{"code":"20975","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1672.000,"maximum":5841.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"OTHER DIGESTIVE SYSTEM O.R. 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"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"154","type":"RC"},{"code":"566","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITHOUT MCC ","code_information":[{"code":"081","type":"MS-DRG"},{"code":"139","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC 2 Day Stay","code_information":[{"code":"157","type":"RC"},{"code":"841","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Suture of extrahepatic biliary duct for pre-existing injury (separate procedure) ","code_information":[{"code":"47900","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":18537.200,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":13523.270,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":16502.980,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":16502.980,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":17520.090,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":18537.200,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION 2 Day Stay","code_information":[{"code":"110","type":"RC"},{"code":"317","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"ENDOCRINE DISORDERS WITH CC ","code_information":[{"code":"115","type":"RC"},{"code":"644","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. 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"}]}]},{"description":"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC ","code_information":[{"code":"135","type":"RC"},{"code":"327","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC ","code_information":[{"code":"121","type":"RC"},{"code":"154","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. 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"}]}]},{"description":"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC 2 Day Stay","code_information":[{"code":"143","type":"RC"},{"code":"760","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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"}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC ","code_information":[{"code":"127","type":"RC"},{"code":"446","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"167","type":"RC"},{"code":"909","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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"}]}]},{"description":"Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording a ","code_information":[{"code":"490","type":"RC"},{"code":"93654","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10185.000,"maximum":53744.760,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":38622.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":48227.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":48227.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":51088.180,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":53744.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":43890.000,"methodology":"case rate"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":21231.000,"methodology":"case rate"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":10694.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":10185.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":24622.000,"methodology":"case rate"}]}]},{"description":"SEIZURES WITH MCC ","code_information":[{"code":"100","type":"MS-DRG"},{"code":"117","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC Pediatric","code_information":[{"code":"027","type":"MS-DRG"},{"code":"143","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":38607.000,"maximum":51623.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":38607.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":43748.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":51623.000,"methodology":"case rate"}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WIT ","code_information":[{"code":"148","type":"RC"},{"code":"497","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"141","type":"RC"},{"code":"819","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen ","code_information":[{"code":"319","type":"RC"},{"code":"88331","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":149.160,"maximum":270.690,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":270.690,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":270.690,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":149.160,"methodology":"fee schedule"}]}]},{"description":"Ethosuximide ","code_information":[{"code":"306","type":"RC"},{"code":"80168","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.000,"maximum":56.880,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":56.880,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":56.880,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16.340,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":14.000,"methodology":"fee schedule"}]}]},{"description":"Angiography, pulmonary, bilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"344","type":"RC"},{"code":"75743","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":151.320,"maximum":508.740,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":508.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":508.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":151.320,"methodology":"fee schedule"}]}]},{"description":"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY 2 Day Stay","code_information":[{"code":"120","type":"RC"},{"code":"770","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"ENDOCRINE DISORDERS WITH MCC ","code_information":[{"code":"113","type":"RC"},{"code":"643","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"EPISTAXIS WITH MCC ","code_information":[{"code":"135","type":"RC"},{"code":"150","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC 4 Day Stay","code_information":[{"code":"121","type":"RC"},{"code":"862","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Radiologic examination, femur; minimum 2 views ","code_information":[{"code":"409","type":"RC"},{"code":"73552","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":36.470,"maximum":182.030,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":98.270,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":98.270,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":182.030,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":36.470,"methodology":"fee schedule"}]}]},{"description":"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC 4 Day Stay","code_information":[{"code":"100","type":"RC"},{"code":"432","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA Pediatric","code_information":[{"code":"133","type":"RC"},{"code":"894","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5135.000,"maximum":6865.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5135.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5818.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6865.000,"methodology":"case rate"}]}]},{"description":"DIABETES WITH CC 2 Day Stay","code_information":[{"code":"136","type":"RC"},{"code":"638","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC ","code_information":[{"code":"082","type":"MS-DRG"},{"code":"144","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Dermabind dl, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"344","type":"RC"},{"code":"Q4287","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC A ","code_information":[{"code":"061","type":"MS-DRG"},{"code":"149","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"AFTERCARE WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"158","type":"RC"},{"code":"950","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 3 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"955","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during the same patient encounter ","code_information":[{"code":"320","type":"RC"},{"code":"76510","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":70.210,"maximum":411.740,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":411.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":411.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":70.210,"methodology":"fee schedule"}]}]},{"description":"Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming ","code_information":[{"code":"362","type":"RC"},{"code":"62362","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":5487.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, axatilimab-csfr, 0.1 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J9038","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":91.820,"maximum":91.820,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":91.820,"methodology":"fee schedule"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH CC ","code_information":[{"code":"100","type":"RC"},{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"144","type":"RC"},{"code":"192","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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"}]}]},{"description":"Antibody; HIV-1 and HIV-2, single result ","code_information":[{"code":"319","type":"RC"},{"code":"86703","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.750,"maximum":47.710,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":47.710,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":47.710,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":11.750,"methodology":"fee schedule"}]}]},{"description":"Excision of torus mandibularis ","code_information":[{"code":"21031","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC Pediatric","code_information":[{"code":"203","type":"RC"},{"code":"267","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":98947.000,"maximum":132303.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":98947.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":112121.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":132303.000,"methodology":"case rate"}]}]},{"description":"MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC ","code_information":[{"code":"128","type":"RC"},{"code":"448","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. 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"}]}]},{"description":"ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY ","code_information":[{"code":"144","type":"RC"},{"code":"173","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH MCC ","code_information":[{"code":"138","type":"RC"},{"code":"299","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; dual lead system ","code_information":[{"code":"33263","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":108436.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":42927.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":53602.420,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":53602.420,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":56782.220,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":59734.900,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic. Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":12167.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":13935.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":11025.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":108436.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":17529.680,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of radial and ulnar shaft fractures; without manipulation ","code_information":[{"code":"25560","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":91.560,"maximum":5841.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":107.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":648.310,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":791.050,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":791.050,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":840.080,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":889.110,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":91.560,"methodology":"fee schedule"}]}]},{"description":"Arthroscopically aided treatment of tibial fracture, proximal (plateau); bicondylar, includes internal fixation, when performed (includes arthroscopy) ","code_information":[{"code":"29856","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":31298.870,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":8386.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":22492.340,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":28085.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":28085.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":29751.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":31298.870,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9124.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":7128.440,"methodology":"fee schedule"}]}]},{"description":"LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT 4 Day Stay","code_information":[{"code":"005","type":"MS-DRG"},{"code":"141","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC ","code_information":[{"code":"122","type":"RC"},{"code":"441","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Phosphorus inorganic (phosphate); urine ","code_information":[{"code":"84105","type":"CPT"},{"code":"841052","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":4.810,"maximum":21.130,"gross_charge":756.34,"discounted_cash":756.34,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":5.830,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":5.250,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":6.070,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":13.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":16.130,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":16.130,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":17.170,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":18.150,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":15.790,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":17.940,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":21.130,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":11.440,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":5.010,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":11.560,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":15.530,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":6.300,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":5.350,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":14.050,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":5.350,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":5.350,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":5.350,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":12.140,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":13.580,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":6.070,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":6.070,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":6.130,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":6.130,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":6.130,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":6.130,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":6.130,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":6.070,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":8.960,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":6.070,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":6.070,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":6.070,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":4.810,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":6.260,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":5.900,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":6.940,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":5.660,"methodology":"fee schedule"}]}]},{"description":"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC 3 Day Stay","code_information":[{"code":"135","type":"RC"},{"code":"629","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC 4 Day Stay","code_information":[{"code":"094","type":"MS-DRG"},{"code":"114","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material ","code_information":[{"code":"70480","type":"CPT"},{"code":"920","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":109.020,"maximum":109.020,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":109.020,"methodology":"fee schedule"}]}]},{"description":"Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with strain imaging ","code_information":[{"code":"402","type":"RC"},{"code":"C9762","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":426.360,"maximum":426.360,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":426.360,"methodology":"fee schedule"}]}]},{"description":"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC 3 Day Stay","code_information":[{"code":"145","type":"RC"},{"code":"579","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC ","code_information":[{"code":"135","type":"RC"},{"code":"240","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"COAGULATION DISORDERS 3 Day Stay","code_information":[{"code":"132","type":"RC"},{"code":"813","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"CARDIAC ARREST, UNEXPLAINED WITH CC ","code_information":[{"code":"147","type":"RC"},{"code":"297","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Reconstruction, angular deformity of toe, soft tissue procedures only (eg, overlapping second toe, fifth toe, curly toes) ","code_information":[{"code":"28313","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC 4 Day Stay","code_information":[{"code":"129","type":"RC"},{"code":"433","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Capsulorrhaphy, anterior, any type; with coracoid process transfer ","code_information":[{"code":"23462","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":10131.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7577.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8586.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":10131.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of submandibular (submaxillary) gland ","code_information":[{"code":"360","type":"RC"},{"code":"42440","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12756.890,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":2467.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9167.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11447.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11447.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12126.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12756.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2096.960,"methodology":"fee schedule"}]}]},{"description":"Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with simple or intermediate repair ","code_information":[{"code":"11470","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":5487.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC 3 Day Stay","code_information":[{"code":"145","type":"RC"},{"code":"963","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass ","code_information":[{"code":"32853","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC 3 Day Stay","code_information":[{"code":"128","type":"RC"},{"code":"856","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Cystourethroscopy; with ureteral meatotomy, unilateral or bilateral ","code_information":[{"code":"52290","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":422.000,"maximum":3589.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3589.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2768.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2768.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":2630.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":3257.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1904.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":672.380,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":718.080,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":718.080,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":718.080,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":718.080,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":646.270,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":422.000,"methodology":"case rate"}]}]},{"description":"CARDIAC ARREST, UNEXPLAINED WITH CC 4 Day Stay","code_information":[{"code":"147","type":"RC"},{"code":"297","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH M 4 Day Stay","code_information":[{"code":"157","type":"RC"},{"code":"640","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Embolectomy or thrombectomy, with or without catheter; innominate, subclavian artery, by thoracic incision ","code_information":[{"code":"34051","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":13360.810,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9746.990,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11894.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11894.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12627.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13360.810,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"113","type":"RC"},{"code":"136","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay ºEIA», enzyme-linked immunosorbent assay ºELISA», fluorescence immunoassay ºFIA», immunochemiluminometric assay ºIMC ","code_information":[{"code":"311","type":"RC"},{"code":"87337","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.260,"maximum":41.740,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":41.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":41.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":10.260,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences ","code_information":[{"code":"321","type":"RC"},{"code":"70553","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":339.460,"maximum":1134.600,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1134.600,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1134.600,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":339.460,"methodology":"fee schedule"}]}]},{"description":"SOFT TISSUE PROCEDURES WITH MCC 3 Day Stay","code_information":[{"code":"146","type":"RC"},{"code":"500","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC 4 Day Stay","code_information":[{"code":"151","type":"RC"},{"code":"840","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"153","type":"RC"},{"code":"349","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Sperm antibodies ","code_information":[{"code":"300","type":"RC"},{"code":"89325","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.670,"maximum":37.170,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":37.170,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":37.170,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10.670,"methodology":"fee schedule"}]}]},{"description":"MOUTH PROCEDURES WITH CC/MCC 3 Day Stay","code_information":[{"code":"128","type":"RC"},{"code":"137","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"DIGESTIVE MALIGNANCY WITH MCC 3 Day Stay","code_information":[{"code":"110","type":"RC"},{"code":"374","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Preparation of fecal microbiota for instillation, including assessment of donor specimen ","code_information":[{"code":"44705","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":734.810,"maximum":5055.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":734.810,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":896.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":896.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":951.980,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1007.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"Selective catheter placement, arterial system; 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schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":44.080,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":98.270,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":84.920,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":42.460,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":42.460,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":42.870,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":42.870,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":42.870,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":42.870,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":42.870,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":42.460,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":62.680,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":42.460,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":42.460,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":42.460,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":40.440,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":41.250,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":48.530,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":39.630,"methodology":"fee schedule"}]}]},{"description":"Laryngoscopy direct, with or without tracheoscopy; diagnostic, except newborn ","code_information":[{"code":"31525","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":314.000,"maximum":13127.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3589.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2768.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2768.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":2630.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":3257.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1904.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":541.480,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":13127.000,"methodology":"case rate"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":578.280,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":578.280,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":578.280,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":578.280,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":520.450,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":314.000,"methodology":"case rate"}]}]},{"description":"Antibody; Campylobacter ","code_information":[{"code":"309","type":"RC"},{"code":"86625","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.240,"maximum":45.680,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":45.680,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":45.680,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.120,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":11.240,"methodology":"fee schedule"}]}]},{"description":"MOUTH PROCEDURES WITH CC/MCC ","code_information":[{"code":"123","type":"RC"},{"code":"137","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Elastase, pancreatic (EL-1), fecal; qualitative or semi-quantitative ","code_information":[{"code":"310","type":"RC"},{"code":"82656","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.880,"maximum":40.160,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":40.160,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":40.160,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":9.880,"methodology":"fee schedule"}]}]},{"description":"MAJOR BLADDER PROCEDURES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"141","type":"RC"},{"code":"655","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Injection, metoprolol tartrate, 1 mg ","drug_information":{"unit":5.000000000000000e+000,"type":"ME"},"code_information":[{"code":"112609","type":"CDM"},{"code":"636","type":"RC"},{"code":"J0616","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.200,"maximum":0.200,"gross_charge":12.37,"discounted_cash":12.37,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.200,"methodology":"fee schedule"}]}]},{"description":"Adapter/extension, pacing lead or neurostimulator lead (implantable) ","code_information":[{"code":"C1883","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":748.580,"maximum":792.610,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":792.610,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":748.580,"methodology":"fee schedule"}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITH MCC 4 Day Stay","code_information":[{"code":"156","type":"RC"},{"code":"444","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EX ","code_information":[{"code":"169","type":"RC"},{"code":"457","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Cardiotomy, exploratory (includes removal of foreign body, atrial or ventricular thrombus); with cardiopulmonary bypass ","code_information":[{"code":"33315","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":25816.850,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":18833.930,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":22983.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":22983.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":24400.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25816.850,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"IV OCT FOR PROC INIT VESSEL ","code_information":[{"code":"0291T","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER DISORDERS OF NERVOUS SYSTEM WITH CC 4 Day Stay","code_information":[{"code":"092","type":"MS-DRG"},{"code":"117","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC ","code_information":[{"code":"001","type":"MS-DRG"},{"code":"100","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"CELLULITIS WITH MCC 2 Day Stay","code_information":[{"code":"110","type":"RC"},{"code":"602","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"SIGNS AND SYMPTOMS WITHOUT MCC ","code_information":[{"code":"142","type":"RC"},{"code":"948","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Vitamin A ","code_information":[{"code":"84590","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":9.950,"maximum":11.610,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.610,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":9.950,"methodology":"fee schedule"}]}]},{"description":"MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC ","code_information":[{"code":"158","type":"RC"},{"code":"330","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETER ","code_information":[{"code":"219","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.000,"maximum":176759.570,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":90935.000,"methodology":"case rate"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":70163.000,"methodology":"case rate"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":64952.450,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":70163.000,"methodology":"case rate"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":66665.000,"methodology":"case rate"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":82544.000,"methodology":"case rate"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":48276.000,"methodology":"case rate"},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_dollar":64497.720,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_dollar":80622.150,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":65807.950,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":69098.350,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 8. "},{"payer_name":"Averde Health","plan_name":"COMM","standard_charge_percentage":33.00,"standard_charge_algorithm":"Reimbursement will be 33% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":116432.320,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $751194.00, charges over the threshold will be paid at 15.3% of billable gross charges in addition to the contracteded rate."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":175244.740,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $751194.00, charges over the threshold will be paid at 18.7% of billable gross charges in addition to the contracteded rate."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":175244.740,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $751194.00, charges over the threshold will be paid at 18.7% of billable gross charges in addition to the contracteded rate."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":176002.160,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $751194.00, charges over the threshold will be paid at 19.9% of billable gross charges in addition to the contracteded rate."},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":65807.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":65807.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":65807.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":176759.570,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $751194.00, charges over the threshold will be paid at 21% of billable gross charges in addition to the contracteded rate."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":65149.870,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":65149.870,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":65149.870,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":65149.870,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":65149.870,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":93164.310,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":104793.440,"methodology":"fee schedule"},{"payer_name":"First Health","plan_name":"Exclusive","standard_charge_dollar":52939.000,"methodology":"case rate"},{"payer_name":"First Health","plan_name":"NonExclusive","standard_charge_dollar":55056.000,"methodology":"case rate"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":94105.370,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":62.00,"standard_charge_algorithm":"Reimbursement will be 62% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"SOUTHTEXASISDRATES","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":62846.590,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":116449.100,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":62846.590,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":62846.590,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":62846.590,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":62846.590,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":116449.100,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":106997.110,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":71730.670,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":121678.020,"methodology":"fee schedule"},{"payer_name":"MultiPlan","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":98810.640,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":95594.840,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":69098.350,"methodology":"fee schedule"},{"payer_name":"PPO Next/ Medical Control","plan_name":"COMMPPO","standard_charge_percentage":75.00,"standard_charge_algorithm":"Reimbursement will be 75% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":69098.350,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":67124.110,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":67124.110,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":67124.110,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":67124.110,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":67124.110,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":82259.940,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":102002.320,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":69098.350,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":69098.350,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":69098.350,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.000,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.000,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":65807.950,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":69098.350,"methodology":"fee schedule"},{"payer_name":"Texas Workforce Commission","plan_name":"WORKERSCOMP","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":65807.950,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":86683.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"United","plan_name":"GlobalBenefitPlan","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":65084.060,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":16.10,"standard_charge_algorithm":"Reimbursement will be 16.1% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":71072.590,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":66071.180,"methodology":"fee schedule"}]}]},{"description":"OTHER CEREBROVASCULAR DISORDERS WITH MCC ","code_information":[{"code":"070","type":"MS-DRG"},{"code":"167","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"CERVICAL SPINAL FUSION WITH CC ","code_information":[{"code":"154","type":"RC"},{"code":"472","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm ","code_information":[{"code":"11622","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2946.000,"maximum":5055.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Complete (cbc), automated (hgb, hct, rbc, wbc; without platelet count) ","code_information":[{"code":"302","type":"RC"},{"code":"G0307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5.540,"maximum":6.470,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6.470,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":5.540,"methodology":"fee schedule"}]}]},{"description":"REPAIR ARTERY RUPTURE ","code_information":[{"code":"35162","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/ 3 Day Stay","code_information":[{"code":"112","type":"RC"},{"code":"941","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC 4 Day Stay","code_information":[{"code":"123","type":"RC"},{"code":"354","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC ","code_information":[{"code":"142","type":"RC"},{"code":"155","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT 3 Day Stay","code_information":[{"code":"121","type":"RC"},{"code":"741","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Acute hepatitis panel This panel must include the following: Hepatitis A antibody (HAAb), IgM antibody (86709) Hepatitis B core antibody (HBcAb), IgM antibody (86705) Hepatitis B surface antigen (HBsA ","code_information":[{"code":"311","type":"RC"},{"code":"80074","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.240,"maximum":165.840,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":165.840,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":165.840,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":8.240,"methodology":"fee schedule"}]}]},{"description":"OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC 4 Day Stay","code_information":[{"code":"155","type":"RC"},{"code":"749","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC 2 Day Stay","code_information":[{"code":"144","type":"RC"},{"code":"871","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Gastrointestinal endoscopic ultrasound, supervision and interpretation ","code_information":[{"code":"322","type":"RC"},{"code":"76975","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":112.550,"maximum":340.350,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":340.350,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":340.350,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":112.550,"methodology":"fee schedule"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH CC ","code_information":[{"code":"0DL74ZZ","type":"ICD"},{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2950.000,"maximum":2950.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2950.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC 3 Day Stay","code_information":[{"code":"112","type":"RC"},{"code":"146","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Hystscp div IU septum ","code_information":[{"code":"360","type":"RC"},{"code":"56353","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC 3 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"392","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Reoperation, carotid, thromboendarterectomy, more than 1 month after original operation (List separately in addition to code for primary procedure) ","code_information":[{"code":"35390","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12018.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1568.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1913.930,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1913.930,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":2031.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2149.850,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC* ","code_information":[{"code":"432","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12897.560,"maximum":12897.560,"payers_information":[{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":12897.560,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, femur; 1 view ","code_information":[{"code":"400","type":"RC"},{"code":"73551","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":29.990,"maximum":182.030,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":83.480,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":83.480,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":182.030,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":29.990,"methodology":"fee schedule"}]}]},{"description":"HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC ","code_information":[{"code":"159","type":"RC"},{"code":"970","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC 4 Day Stay","code_information":[{"code":"142","type":"RC"},{"code":"831","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Oncology (prostate), exosome-based analysis of 442 small noncoding RNAs by quantitative reverse transcription polymerase chain reaction, urine, reported as molecular evidence of no-, low-, intermediat ","code_information":[{"code":"0343U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":760.000,"maximum":760.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":760.000,"methodology":"fee schedule"}]}]},{"description":"VIRAL ILLNESS WITHOUT MCC ","code_information":[{"code":"164","type":"RC"},{"code":"866","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY ","code_information":[{"code":"133","type":"RC"},{"code":"173","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"Diphtheria and tetanus toxoids adsorbed (DT) when administered to individuals younger than 7 years, for intramuscular use ","code_information":[{"code":"343","type":"RC"},{"code":"90702","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30.310,"maximum":30.310,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":30.310,"methodology":"fee schedule"}]}]},{"description":"PROSTATECTOMY WITH CC ","code_information":[{"code":"100","type":"RC"},{"code":"666","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"PROSTATECTOMY WITH MCC ","code_information":[{"code":"141","type":"RC"},{"code":"665","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis ","code_information":[{"code":"81415","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4684.400,"maximum":17461.340,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":4820.630,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":4780.000,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":5019.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10946.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":13336.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":13336.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14196.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":4780.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":4780.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":4780.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15009.200,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":13049.400,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":14820.390,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":17461.340,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":4780.000,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":4780.000,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":4780.000,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":4780.000,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":4780.000,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":9464.400,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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"}]}]},{"description":"ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES ","code_information":[{"code":"123","type":"RC"},{"code":"213","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"OTHER CIRCULATORY SYSTEM O.R. PROCEDURES 2 Day Stay","code_information":[{"code":"152","type":"RC"},{"code":"264","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"148","type":"MS-DRG"},{"code":"153","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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"}]}]},{"description":"Transcatheter mitral valve repair percutaneous approach via the coronary sinus ","code_information":[{"code":"0345T","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Incision and drainage, pelvis or hip joint area; infected bursa ","code_information":[{"code":"26991","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":636.360,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2561.690,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3198.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3198.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3388.480,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3564.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":636.360,"methodology":"fee schedule"}]}]},{"description":"Repair of graft-enteric fistula ","code_information":[{"code":"35870","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":16690.530,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":12176.090,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14858.960,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14858.960,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":15774.740,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16690.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Ureterolithotomy; lower one-third of ureter ","code_information":[{"code":"50630","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3061.000,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Injection, ertapenem sodium, 500 mg ","code_information":[{"code":"343","type":"RC"},{"code":"J1335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":15.110,"maximum":15.110,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15.110,"methodology":"fee schedule"}]}]},{"description":"Closure of rectovesical fistula; ","code_information":[{"code":"45800","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":17017.010,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":12414.260,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":15149.610,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":15149.610,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":16083.310,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17017.010,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health 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schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":68.170,"methodology":"fee schedule"}]}]},{"description":"Penile venous occlusive procedure ","code_information":[{"code":"369","type":"RC"},{"code":"37790","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4988.000,"maximum":15410.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5705.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7123.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7123.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7546.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7938.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"}]}]},{"description":"Excision of urethral diverticulum (separate procedure); male ","code_information":[{"code":"361","type":"RC"},{"code":"53235","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12635.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":2132.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":7997.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":9986.620,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":9986.620,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":10579.050,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11129.160,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case 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","code_information":[{"code":"0024","type":"RC"},{"code":"C1401","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":16293.940,"maximum":16293.940,"payers_information":[{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":16293.940,"methodology":"fee schedule"}]}]},{"description":"Hepatitis C antibody; ","code_information":[{"code":"306","type":"RC"},{"code":"86803","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.230,"maximum":49.660,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":49.660,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":49.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14.270,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":12.230,"methodology":"fee schedule"}]}]},{"description":"PERIPHERAL VASCULAR 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"}]}]},{"description":"Ostectomy, complete excision; first metatarsal head ","code_information":[{"code":"28111","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC ","code_information":[{"code":"115","type":"RC"},{"code":"521","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Neothelium ft, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"343","type":"RC"},{"code":"Q4387","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or resulting in removal of less than 100 sq mm surface area o ","code_information":[{"code":"369","type":"RC"},{"code":"69716","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":33120.350,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":7906.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":23801.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":29720.160,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":29720.160,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":31483.230,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":33120.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":6720.770,"methodology":"fee schedule"}]}]},{"description":"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC 3 Day Stay","code_information":[{"code":"157","type":"RC"},{"code":"734","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"120","type":"RC"},{"code":"903","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber syste High Cost Surgery","code_information":[{"code":"33225","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2369.000,"maximum":2369.000,"payers_information":[{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":2369.000,"methodology":"case rate"}]}]},{"description":"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC 3 Day Stay","code_information":[{"code":"160","type":"RC"},{"code":"256","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"KIDNEY AND URINARY TRACT INFECTIONS WITH MCC ","code_information":[{"code":"153","type":"RC"},{"code":"689","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2958.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"}]}]},{"description":"Injection, basiliximab, 20 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J0480","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":7888.770,"maximum":7888.770,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7888.770,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination; acromioclavicular joints, bilateral, with or without weighted distraction ","code_information":[{"code":"349","type":"RC"},{"code":"73050","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":29.310,"maximum":106.800,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":106.800,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":106.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":29.310,"methodology":"fee schedule"}]}]},{"description":"OTHER VASCULAR PROCEDURES WITH CC 3 Day Stay","code_information":[{"code":"164","type":"RC"},{"code":"253","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC A 4 Day Stay","code_information":[{"code":"062","type":"MS-DRG"},{"code":"118","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC ","code_information":[{"code":"140","type":"RC"},{"code":"357","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC 3 Day Stay","code_information":[{"code":"122","type":"RC"},{"code":"448","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC ","code_information":[{"code":"101","type":"RC"},{"code":"815","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC ","code_information":[{"code":"115","type":"RC"},{"code":"235","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"REPAIR UMBILICAL HERNIA, YOUNGER THAN AGE 5 YEARS; REDUCIBLE ","code_information":[{"code":"49580","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4988.000,"maximum":8328.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"}]}]},{"description":"CERVICAL SPINAL FUSION WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"157","type":"RC"},{"code":"473","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT C ","code_information":[{"code":"116","type":"RC"},{"code":"443","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Repair nasal septal perforations ","code_information":[{"code":"30630","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":877.750,"maximum":13607.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":13607.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":10498.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":10498.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":9975.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":12351.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":7223.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":913.220,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":975.280,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":975.280,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":975.280,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":975.280,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":877.750,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":941.000,"methodology":"case rate"}]}]},{"description":"Endovascular temporary balloon arterial occlusion, head or neck (extracranial/intracranial) including selective catheterization of vessel to be occluded, positioning and inflation of occlusion balloon ","code_information":[{"code":"481","type":"RC"},{"code":"61623","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":26059.300,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":18727.030,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":23384.010,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":23384.010,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":24771.200,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26059.300,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":9875.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":10949.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":13197.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":10185.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16496.000,"methodology":"case rate"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC 2 Day Stay","code_information":[{"code":"116","type":"RC"},{"code":"818","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"AFTERCARE WITHOUT CC/MCC Pediatric","code_information":[{"code":"133","type":"RC"},{"code":"950","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8661.000,"maximum":11580.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":8661.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":9814.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":11580.000,"methodology":"case rate"}]}]},{"description":"Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological s ","code_information":[{"code":"369","type":"RC"},{"code":"50694","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1226.380,"maximum":15410.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1442.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5705.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7123.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7123.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7546.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7938.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":9999.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":11331.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":13370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1226.380,"methodology":"fee schedule"}]}]},{"description":"NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"157","type":"RC"},{"code":"989","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"BRONCHITIS AND ASTHMA WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"147","type":"RC"},{"code":"203","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC 3 Day Stay","code_information":[{"code":"133","type":"RC"},{"code":"469","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"151","type":"RC"},{"code":"761","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. 2 Day Stay","code_information":[{"code":"138","type":"RC"},{"code":"826","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC Pediatric","code_information":[{"code":"113","type":"RC"},{"code":"657","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":32808.000,"maximum":43868.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":32808.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":37176.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":43868.000,"methodology":"case rate"}]}]},{"description":"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"128","type":"RC"},{"code":"244","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Biopsy of palate, uvula ","code_information":[{"code":"362","type":"RC"},{"code":"42100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2946.000,"maximum":5055.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Corpora cavernosa-glans penis fistulization (eg, biopsy needle, Winter procedure, rongeur, or punch) for priapism ","code_information":[{"code":"360","type":"RC"},{"code":"54435","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15410.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1442.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5705.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7123.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7123.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7546.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7938.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1226.380,"methodology":"fee schedule"}]}]},{"description":"FOOT PROCEDURES WITH CC ","code_information":[{"code":"114","type":"RC"},{"code":"504","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), including all radiological supervision and interpretation, int ","code_information":[{"code":"369","type":"RC"},{"code":"61624","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":16496.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11468.470,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":13995.420,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":13995.420,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14857.980,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15720.550,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":9875.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16496.000,"methodology":"case rate"}]}]},{"description":"ENDOCRINE DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"101","type":"RC"},{"code":"645","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC Pediatric","code_information":[{"code":"074","type":"MS-DRG"},{"code":"143","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":14362.000,"maximum":19203.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":14362.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":16274.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19203.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, ribs, bilateral; 3 views ","code_information":[{"code":"71110","type":"CPT"},{"code":"924","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":44.980,"maximum":44.980,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":44.980,"methodology":"fee schedule"}]}]},{"description":"INTRAOCULAR PROCEDURES WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"117","type":"MS-DRG"},{"code":"147","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"LIVER TRANSPLANT WITHOUT MCC ","code_information":[{"code":"006","type":"MS-DRG"},{"code":"122","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITH CC ","code_information":[{"code":"149","type":"RC"},{"code":"975","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WIT ","code_information":[{"code":"118","type":"RC"},{"code":"562","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) High Cost Surgery","code_information":[{"code":"360","type":"RC"},{"code":"58671","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2369.000,"maximum":2369.000,"payers_information":[{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":2369.000,"methodology":"case rate"}]}]},{"description":"Nerve teasing preparations 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3198.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3198.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3388.480,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3564.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":636.360,"methodology":"fee schedule"}]}]},{"description":"MAJOR BLADDER PROCEDURES WITH CC 2 Day Stay","code_information":[{"code":"121","type":"RC"},{"code":"654","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC Pediatric","code_information":[{"code":"072","type":"MS-DRG"},{"code":"143","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":11265.000,"maximum":15062.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":11265.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":12765.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":15062.000,"methodology":"case rate"}]}]},{"description":"Excision dermoid cyst, nose; complex, under bone or cartilage ","code_information":[{"code":"30125","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2096.960,"maximum":12756.890,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9167.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11447.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11447.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12126.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12756.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2096.960,"methodology":"fee schedule"}]}]},{"description":"Tenolysis, flexor, foot; multiple tendons High Cost Surgery","code_information":[{"code":"28222","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2369.000,"maximum":2369.000,"payers_information":[{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":2369.000,"methodology":"case rate"}]}]},{"description":"Thromboendarterectomy, including patch graft, if performed; iliac ","code_information":[{"code":"35351","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":17296.770,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":12618.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":15398.670,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":15398.670,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":16347.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17296.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"ORBITAL PROCEDURES WITHOUT CC/MCC Pediatric","code_information":[{"code":"114","type":"MS-DRG"},{"code":"133","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":15417.000,"maximum":20615.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":15417.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":17470.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":20615.000,"methodology":"case rate"}]}]},{"description":"OTITIS MEDIA AND URI WITH MCC 4 Day Stay","code_information":[{"code":"123","type":"RC"},{"code":"152","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Neuroplasty and/or transposition; ulnar nerve at elbow ","code_information":[{"code":"367","type":"RC"},{"code":"64718","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":5487.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DIABETES WITH CC ","code_information":[{"code":"119","type":"RC"},{"code":"638","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Ultrasound, elastography; parenchyma (eg, organ) ","code_information":[{"code":"76981","type":"CPT"},{"code":"920","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":106.680,"maximum":106.680,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":106.680,"methodology":"fee schedule"}]}]},{"description":"NERVOUS SYSTEM NEOPLASMS WITH MCC 3 Day Stay","code_information":[{"code":"054","type":"MS-DRG"},{"code":"154","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"136","type":"RC"},{"code":"583","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC 3 Day Stay","code_information":[{"code":"151","type":"RC"},{"code":"576","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/ 4 Day Stay","code_information":[{"code":"022","type":"MS-DRG"},{"code":"139","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Abdomino-vaginal vesical neck suspension, with or without endoscopic control (eg, Stamey, Raz, modified Pereyra) ","code_information":[{"code":"499","type":"RC"},{"code":"51845","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8073.210,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":10080.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":10080.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":10678.850,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11234.150,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"}]}]},{"description":"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC ","code_information":[{"code":"100","type":"RC"},{"code":"438","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"PLEURAL EFFUSION WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"147","type":"RC"},{"code":"188","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"PABPN1 (polyºA» binding protein nuclear 1) (eg, oculopharyngeal muscular dystrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"301","type":"RC"},{"code":"81312","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":137.000,"maximum":137.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":137.000,"methodology":"fee schedule"}]}]},{"description":"CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC 2 Day Stay","code_information":[{"code":"148","type":"RC"},{"code":"307","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC ","code_information":[{"code":"121","type":"RC"},{"code":"438","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Intraoperative radiation treatment delivery, x-ray, single treatment session ","code_information":[{"code":"77424","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":642.280,"maximum":59359.870,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":642.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":784.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":784.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":833.040,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":881.330,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":44379.240,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":50287.090,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":59359.870,"methodology":"fee schedule"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. 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dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":5766.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":5766.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6108.470,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6426.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative 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"}]}]},{"description":"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC 3 Day Stay","code_information":[{"code":"025","type":"MS-DRG"},{"code":"131","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"LUNG TRANSPLANT ","code_information":[{"code":"007","type":"MS-DRG"},{"code":"141","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"NERVOUS SYSTEM NEOPLASMS WITH MCC ","code_information":[{"code":"054","type":"MS-DRG"},{"code":"135","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC 3 Day Stay","code_information":[{"code":"118","type":"RC"},{"code":"356","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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"}]}]},{"description":"SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL ","code_information":[{"code":"169","type":"RC"},{"code":"402","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Fragmentation in Bladder Neck, External Approach ","code_information":[{"code":"0TFCXZZ","type":"ICD"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":2905.000,"maximum":2905.000,"payers_information":[{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":2905.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":2905.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":2905.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":2905.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":2905.000,"methodology":"case rate"}]}]},{"description":"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"117","type":"RC"},{"code":"440","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Excision of tracheal tumor or carcinoma; thoracic ","code_information":[{"code":"31786","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":19465.250,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":14200.310,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":17329.190,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":17329.190,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":18397.220,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":19465.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"100","type":"RC"},{"code":"285","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"COMPLEX AORTIC ARCH PROCEDURES Pediatric","code_information":[{"code":"153","type":"RC"},{"code":"209","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":136625.000,"maximum":182681.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":136625.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":154815.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":182681.000,"methodology":"case rate"}]}]},{"description":"Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance ","code_information":[{"code":"37187","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":15581.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9362.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11691.230,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11691.230,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12384.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13028.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":9999.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":11331.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":13370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":5739.300,"methodology":"fee schedule"}]}]},{"description":"Blood, occult, by peroxidase activity (eg, guaiac), qualitative; other sources ","code_information":[{"code":"82271","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.430,"maximum":19.450,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":5.370,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":4.830,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":5.320,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":5.590,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":12.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":15.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":5.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":5.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":5.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16.700,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":14.530,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":16.500,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":19.450,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":5.320,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":5.320,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":5.320,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":5.320,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":5.320,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":10.530,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":4.600,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":10.640,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":12.930,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":5.320,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":5.320,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":5.320,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":5.320,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":5.320,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":5.320,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":5.800,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":4.920,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":12.930,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":4.920,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":4.920,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":4.920,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":11.170,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":12.500,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":5.590,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":5.590,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":5.640,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":5.640,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":5.640,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":5.640,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":5.640,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":5.590,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":8.250,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":5.590,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":5.590,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":5.590,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":4.430,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":5.760,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":5.320,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":5.430,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":6.380,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":5.210,"methodology":"fee schedule"}]}]},{"description":"Ileoscopy, through stoma; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) ","code_information":[{"code":"44384","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2434.000,"maximum":8444.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5668.260,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7077.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7077.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7497.700,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7887.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, head or brain; with contrast material(s) ","code_information":[{"code":"341","type":"RC"},{"code":"70460","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":156.430,"maximum":490.170,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":490.170,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":490.170,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":156.430,"methodology":"fee schedule"}]}]},{"description":"TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; targeted sequence analysis (eg, 4 oncology) ","code_information":[{"code":"307","type":"RC"},{"code":"81352","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":282.330,"maximum":329.510,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":329.510,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":282.330,"methodology":"fee schedule"}]}]},{"description":"OSTEOMYELITIS WITH MCC ","code_information":[{"code":"149","type":"RC"},{"code":"539","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening under physician supervision ","code_information":[{"code":"300","type":"RC"},{"code":"88166","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.640,"maximum":41.310,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":41.310,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":41.310,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":13.640,"methodology":"fee schedule"}]}]},{"description":"Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, T-cell depletion ","code_information":[{"code":"367","type":"RC"},{"code":"38210","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2946.000,"maximum":5055.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast inje ","code_information":[{"code":"36251","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DIABETES WITH MCC 4 Day Stay","code_information":[{"code":"159","type":"RC"},{"code":"637","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC 4 Day Stay","code_information":[{"code":"126","type":"RC"},{"code":"626","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Leukocyte assessment, fecal, qualitative or semiquantitative ","code_information":[{"code":"311","type":"RC"},{"code":"89055","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3.660,"maximum":14.860,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":14.860,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":14.860,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":3.660,"methodology":"fee schedule"}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCE ","code_information":[{"code":"120","type":"RC"},{"code":"829","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"}]}]},{"description":"CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC 3 Day Stay","code_information":[{"code":"146","type":"RC"},{"code":"236","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Implantation of auditory brain stem implant ","code_information":[{"code":"369","type":"RC"},{"code":"S2235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":13988.660,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10205.020,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12453.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12453.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13221.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13988.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC 3 Day Stay","code_information":[{"code":"073","type":"MS-DRG"},{"code":"145","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar ","code_information":[{"code":"22214","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":20239.450,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":14765.100,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":18018.430,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":18018.430,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":19128.940,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20239.450,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"}]}]},{"description":"Gastrostomy, open; neonatal, for feeding ","code_information":[{"code":"43831","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3061.000,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC ","code_information":[{"code":"131","type":"RC"},{"code":"429","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"122","type":"RC"},{"code":"390","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC 3 Day Stay","code_information":[{"code":"119","type":"RC"},{"code":"555","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Arthrotomy of the elbow, with capsular excision for capsular release (separate procedure) ","code_information":[{"code":"24006","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":15410.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"151","type":"RC"},{"code":"730","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"121","type":"RC"},{"code":"583","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Computed tomography, pelvis; with contrast material(s) ","code_information":[{"code":"72193","type":"CPT"},{"code":"739","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":183.950,"maximum":183.950,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":183.950,"methodology":"fee schedule"}]}]},{"description":"CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC 2 Day Stay","code_information":[{"code":"126","type":"RC"},{"code":"236","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC 2 Day Stay","code_information":[{"code":"127","type":"RC"},{"code":"424","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"BX BREAST PERCUT W/IMAGE ","code_information":[{"code":"19102","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vesiculectomy, any approach ","code_information":[{"code":"481","type":"RC"},{"code":"55650","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2012.000,"maximum":9662.690,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":7049.130,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":8602.330,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":8602.330,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":9132.510,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9662.690,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2012.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2251.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2527.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2650.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2505.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (eg, to assess for residual tumor or residual vascular malformation); without c ","code_information":[{"code":"401","type":"RC"},{"code":"70557","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1155.460,"maximum":1155.460,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1155.460,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1155.460,"methodology":"fee schedule"}]}]},{"description":"MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"123","type":"RC"},{"code":"331","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WI 2 Day Stay","code_information":[{"code":"023","type":"MS-DRG"},{"code":"133","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Cardiopulmonary resuscitation (eg, in cardiac arrest) ","code_information":[{"code":"360","type":"RC"},{"code":"92950","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":478.360,"maximum":2940.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":478.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":597.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":597.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":632.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":665.650,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test ","code_information":[{"code":"307","type":"RC"},{"code":"89330","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.380,"maximum":34.430,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":34.430,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":34.430,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10.380,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); respiratory syncytial virus, amplified probe technique ","code_information":[{"code":"303","type":"RC"},{"code":"87634","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":60.150,"maximum":244.380,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":244.380,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":244.380,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":70.200,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":60.150,"methodology":"fee schedule"}]}]},{"description":"Cholangiography and/or pancreatography; additional set intraoperative, radiological supervision and interpretation (List separately in addition to code for primary procedure) ","code_information":[{"code":"342","type":"RC"},{"code":"74301","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":81.650,"maximum":81.650,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":81.650,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":81.650,"methodology":"fee schedule"}]}]},{"description":"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH 3 Day Stay","code_information":[{"code":"131","type":"RC"},{"code":"618","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve rootºs», ºeg, spinal or lateral recess stenosis»), single vertebral segm ","code_information":[{"code":"369","type":"RC"},{"code":"63046","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2573.700,"maximum":15732.530,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":3027.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11305.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14954.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15732.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":9999.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":11331.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":13370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9124.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2573.700,"methodology":"fee schedule"}]}]},{"description":"UNCOMPLICATED PEPTIC ULCER WITHOUT MCC ","code_information":[{"code":"140","type":"RC"},{"code":"384","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"COMPLICATIONS OF TREATMENT WITH MCC ","code_information":[{"code":"140","type":"RC"},{"code":"919","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"INTERSTITIAL LUNG DISEASE WITH CC 3 Day Stay","code_information":[{"code":"149","type":"RC"},{"code":"197","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, pl ","code_information":[{"code":"369","type":"RC"},{"code":"44378","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":606.240,"maximum":5487.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":713.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2943.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3675.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3675.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3893.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4095.960,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":606.240,"methodology":"fee schedule"}]}]},{"description":"INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC 4 Day Stay","code_information":[{"code":"021","type":"MS-DRG"},{"code":"101","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT 3 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"499","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"120","type":"RC"},{"code":"822","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"116","type":"RC"},{"code":"747","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT 4 Day Stay","code_information":[{"code":"008","type":"MS-DRG"},{"code":"158","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), includes m-mode recording, when performed, complete, without spect ","code_information":[{"code":"C8923","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2893.490,"maximum":3969.180,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2893.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3533.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3533.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3751.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3969.180,"methodology":"fee schedule"}]}]},{"description":"PROSTATECTOMY WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"150","type":"RC"},{"code":"667","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Renal exploration, not necessitating other specific procedures ","code_information":[{"code":"369","type":"RC"},{"code":"50010","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":12018.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":7219.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":8809.920,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":8809.920,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":9352.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9895.860,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, shoulder; complete, minimum of 2 views ","code_information":[{"code":"329","type":"RC"},{"code":"73030","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.450,"maximum":182.030,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":87.820,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":87.820,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":182.030,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":35.450,"methodology":"fee schedule"}]}]},{"description":"Smear, primary source with interpretation; special stain for inclusion bodies or parasites (eg, malaria, coccidia, microsporidia, trypanosomes, herpes viruses) ","code_information":[{"code":"301","type":"RC"},{"code":"87207","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.130,"maximum":20.870,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":20.870,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":20.870,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.990,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":5.130,"methodology":"fee schedule"}]}]},{"description":"SPINAL DISORDERS AND INJURIES WITH CC/MCC 3 Day Stay","code_information":[{"code":"052","type":"MS-DRG"},{"code":"148","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC ","code_information":[{"code":"146","type":"RC"},{"code":"270","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"ENDOCRINE DISORDERS WITH MCC 4 Day Stay","code_information":[{"code":"126","type":"RC"},{"code":"643","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC ","code_information":[{"code":"111","type":"RC"},{"code":"438","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions ","code_information":[{"code":"611","type":"RC"},{"code":"74178","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":363.310,"maximum":363.310,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":363.310,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of proximal tibiofibular joint dislocation; without anesthesia ","code_information":[{"code":"27830","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2946.000,"maximum":5055.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of corneal epithelium; with or without chemocauterization (abrasion, curettage) ","code_information":[{"code":"65435","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":38.370,"maximum":2678.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":2678.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1964.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":2433.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1422.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":39.920,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":42.640,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":42.640,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":42.640,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":42.640,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":38.370,"methodology":"fee schedule"}]}]},{"description":"FOOT PROCEDURES WITH MCC 4 Day Stay","code_information":[{"code":"126","type":"RC"},{"code":"503","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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"}]}]},{"description":"TRANSURETHRAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"114","type":"RC"},{"code":"670","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC ","code_information":[{"code":"169","type":"RC"},{"code":"413","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. 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"}]}]},{"description":"NEUROLOGICAL EYE DISORDERS ","code_information":[{"code":"120","type":"RC"},{"code":"123","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"MOUTH PROCEDURES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"138","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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"}]}]},{"description":"TRANSCATH IV STENT OPEN ","code_information":[{"code":"369","type":"RC"},{"code":"37207","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 4 Day Stay","code_information":[{"code":"152","type":"RC"},{"code":"344","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"MAJOR SKIN DISORDERS WITH MCC ","code_information":[{"code":"169","type":"RC"},{"code":"595","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Intravitreal injection of a pharmacologic agent (separate procedure) ","code_information":[{"code":"360","type":"RC"},{"code":"67028","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":51.990,"maximum":5841.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":61.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":281.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":343.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":343.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":364.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":385.800,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":51.990,"methodology":"fee schedule"}]}]},{"description":"PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH 2 Day Stay","code_information":[{"code":"149","type":"RC"},{"code":"542","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"143","type":"RC"},{"code":"615","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ A 3 Day Stay","code_information":[{"code":"143","type":"RC"},{"code":"321","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Computed tomography, maxillofacial area; with contrast material(s) ","code_information":[{"code":"619","type":"RC"},{"code":"70487","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":160.860,"maximum":160.860,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":160.860,"methodology":"fee schedule"}]}]},{"description":"CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR 3 Day Stay","code_information":[{"code":"154","type":"RC"},{"code":"276","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"OTHER VASCULAR PROCEDURES WITH CC 2 Day Stay","code_information":[{"code":"136","type":"RC"},{"code":"253","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Removal of lens material; extracapsular (other than 66840, 66850, 66852) ","code_information":[{"code":"499","type":"RC"},{"code":"66940","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":912.020,"maximum":9851.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3821.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":4771.590,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":4771.590,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":5054.650,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5317.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7367.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8349.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":912.020,"methodology":"fee schedule"}]}]},{"description":"CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC 2 Day Stay","code_information":[{"code":"155","type":"RC"},{"code":"275","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"SHOULDER ARTHROSCOPY ","code_information":[{"code":"29815","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC 2 Day Stay","code_information":[{"code":"126","type":"RC"},{"code":"749","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Ureterotomy with exploration or drainage (separate procedure) ","code_information":[{"code":"490","type":"RC"},{"code":"50600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12665.930,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9240.060,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11276.010,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11276.010,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":11970.970,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12665.930,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"TRAUMATIC BRAIN INJURY; M > 40.65 & M < 44.25 ","code_information":[{"code":"138","type":"RC"},{"code":"C0204","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":29110.540,"maximum":31730.480,"payers_information":[{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":29110.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":29110.540,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":31730.480,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":30566.060,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":29692.750,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":29692.750,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":29692.750,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":29692.750,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":29692.750,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":30566.060,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited ","code_information":[{"code":"619","type":"RC"},{"code":"76642","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":87.250,"maximum":87.250,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":87.250,"methodology":"fee schedule"}]}]},{"description":"MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"135","type":"RC"},{"code":"346","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Ocular surface reconstruction; limbal conjunctival autograft (includes obtaining graft) ","code_information":[{"code":"65782","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":678.000,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":678.000,"methodology":"case rate"}]}]},{"description":"MAJOR BLADDER PROCEDURES WITH CC 2 Day Stay","code_information":[{"code":"123","type":"RC"},{"code":"654","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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"}]}]},{"description":"PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; full sequence analysis ","code_information":[{"code":"300","type":"RC"},{"code":"81321","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":514.080,"maximum":1692.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1692.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1692.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":600.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":514.080,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with other than vein; popliteal-tibial or -peroneal artery ","code_information":[{"code":"35671","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15058.280,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10985.330,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":13405.820,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":13405.820,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14232.050,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15058.280,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"SKIN DEBRIDEMENT WITH MCC 2 Day Stay","code_information":[{"code":"167","type":"RC"},{"code":"570","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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"}]}]},{"description":"Cardiology (heart transplant), mRNA gene expression progiling by microarray of 1283 genes, transplant biopsy tissue, allograft rejection and injury algorithm reported as a probability score ","code_information":[{"code":"0087U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3159.420,"maximum":3159.420,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3159.420,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, lumbar spine; with contrast material ","code_information":[{"code":"409","type":"RC"},{"code":"72132","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":178.940,"maximum":682.370,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":682.370,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":682.370,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":178.940,"methodology":"fee schedule"}]}]},{"description":"Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"MINOR BLADDER PROCEDURES WITH MCC ","code_information":[{"code":"125","type":"RC"},{"code":"662","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. 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"}]}]},{"description":"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"169","type":"RC"},{"code":"257","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"MAJOR MALE PELVIC PROCEDURES WITH CC/MCC 2 Day Stay","code_information":[{"code":"112","type":"RC"},{"code":"707","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"111","type":"RC"},{"code":"547","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH 4 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"544","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC 2 Day Stay","code_information":[{"code":"116","type":"RC"},{"code":"250","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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"}]}]},{"description":"Exchange nephrostomy catheter, percutaneous, with ureteral stricture balloon dilation, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or flu ","code_information":[{"code":"750","type":"RC"},{"code":"C7548","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":12018.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4594.420,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":5016.030,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":5016.030,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":5134.940,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5243.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES ","code_information":[{"code":"137","type":"RC"},{"code":"213","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. 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"}]}]},{"description":"LAPAROSCOPY, SURGICAL, REPAIR, VENTRAL, UMBILICAL, SPIGELIAN OR EPIGASTRIC HERNIA (INCLUDES MESH INSERTION, WHEN PERFORMED); INCARCERATED OR STRANGULATED ","code_information":[{"code":"361","type":"RC"},{"code":"49653","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":11460.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9124.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"}]}]},{"description":"Collection of blood specimen from a completely implantable venous access device ","code_information":[{"code":"36591","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1672.000,"maximum":5851.000,"payers_information":[{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5851.000,"methodology":"case rate"}]}]},{"description":"Tracheostomy, planned (separate procedure); 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"}]}]},{"description":"Tenotomy, percutaneous, Achilles tendon (separate procedure); general anesthesia ","code_information":[{"code":"27606","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3041.000,"maximum":3041.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISOR 2 Day Stay","code_information":[{"code":"144","type":"RC"},{"code":"623","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Radiologic examination, small intestine, including multiple serial images and scout abdominal radiograph(s), when performed; single-contrast (eg, barium) study ","code_information":[{"code":"74250","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":126.790,"maximum":126.790,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":126.790,"methodology":"fee schedule"}]}]},{"description":"Factor viii nuwiq recomb ","code_information":[{"code":"1846","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1.110,"maximum":2.750,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1.140,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":1.130,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":1.190,"methodology":"fee 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"}]}]},{"description":"Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with drainage ","code_information":[{"code":"361","type":"RC"},{"code":"67440","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15410.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1392.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5910.140,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7379.860,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7379.860,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7817.650,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8224.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7367.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8349.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1184.020,"methodology":"fee schedule"}]}]},{"description":"HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC ","code_information":[{"code":"167","type":"RC"},{"code":"353","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"ACUTE LEUKEMIA WITH CC 3 Day Stay","code_information":[{"code":"131","type":"RC"},{"code":"835","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC ","code_information":[{"code":"117","type":"RC"},{"code":"423","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Computed tomography, abdomen and pelvis; without contrast material ","code_information":[{"code":"340","type":"RC"},{"code":"74176","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":193.590,"maximum":604.870,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":604.870,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":604.870,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":193.590,"methodology":"fee schedule"}]}]},{"description":"Cystoplasty or cystourethroplasty, plastic operation on bladder and/or vesical neck (anterior Y-plasty, vesical fundus resection), any procedure, with or without wedge resection of posterior vesical n ","code_information":[{"code":"499","type":"RC"},{"code":"51800","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":14172.280,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10338.970,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12617.050,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12617.050,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13394.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14172.280,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative 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","code_information":[{"code":"499","type":"RC"},{"code":"D9911","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DIABETES WITH CC ","code_information":[{"code":"167","type":"RC"},{"code":"638","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":4077.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4289.870,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2012.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5851.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":478.870,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling, peritoneal washings, peritoneal biopsy(ies), omentectomy, and diaphragmatic washings, including ","code_information":[{"code":"38573","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case 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"}]}]},{"description":"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC 3 Day Stay","code_information":[{"code":"125","type":"RC"},{"code":"923","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Smear, primary source with interpretation; fluorescent and/or acid fast stain for bacteria, fungi, parasites, viruses or cell types ","code_information":[{"code":"312","type":"RC"},{"code":"87206","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.620,"maximum":18.750,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":18.750,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":18.750,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":4.620,"methodology":"fee schedule"}]}]},{"description":"FRACTURE OF LOWER EXTREMITY; M < 28.15 ","code_information":[{"code":"118","type":"RC"},{"code":"A0704","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":27440.130,"maximum":29909.740,"payers_information":[{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":27440.130,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":27440.130,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":29909.740,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":28812.140,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":27988.940,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":27988.940,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":27988.940,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":27988.940,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":27988.940,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":28812.140,"methodology":"fee schedule"}]}]},{"description":"HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"131","type":"RC"},{"code":"422","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Infusion, albumin (human), 5%, 50 ml ","code_information":[{"code":"343","type":"RC"},{"code":"P9041","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":17.520,"maximum":17.520,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17.520,"methodology":"fee schedule"}]}]},{"description":"TESTES PROCEDURES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"110","type":"RC"},{"code":"712","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH CC 3 Day Stay","code_information":[{"code":"110","type":"RC"},{"code":"300","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"113","type":"RC"},{"code":"328","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Molecular pathology procedure, Level 4 (eg, analysis of single exon by DNA sequence analysis, analysis of >10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or dup ","code_information":[{"code":"305","type":"RC"},{"code":"81403","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":158.680,"maximum":522.260,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":522.260,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":522.260,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":185.200,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":158.680,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; with osteotomy (eg, flatfoot correction) ","code_information":[{"code":"28735","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":31298.870,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":9475.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":22492.340,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":28085.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":28085.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":29751.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":31298.870,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9124.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":8053.900,"methodology":"fee schedule"}]}]},{"description":"PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC 3 Day Stay","code_information":[{"code":"156","type":"RC"},{"code":"243","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"DIGESTIVE MALIGNANCY WITH MCC 2 Day Stay","code_information":[{"code":"147","type":"RC"},{"code":"374","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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"}]}]},{"description":"Excision hyperplastic tissue ","code_information":[{"code":"362","type":"RC"},{"code":"D7970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WIT 3 Day Stay","code_information":[{"code":"117","type":"RC"},{"code":"495","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"HLA typing; A, B, or C, multiple antigens ","code_information":[{"code":"300","type":"RC"},{"code":"86813","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":49.690,"maximum":201.910,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":201.910,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":201.910,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":58.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":49.690,"methodology":"fee schedule"}]}]},{"description":"Blood typing, serologic; antigen screening for compatible unit using patient serum, per unit screened ","code_information":[{"code":"303","type":"RC"},{"code":"86904","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.000,"maximum":46.080,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":46.080,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":46.080,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16.340,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":14.000,"methodology":"fee schedule"}]}]},{"description":"CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC Pediatric","code_information":[{"code":"133","type":"RC"},{"code":"785","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17284.000,"maximum":23112.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":17284.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":19586.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":23112.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, hips, bilateral, with pelvis when performed; minimum of 5 views ","code_information":[{"code":"404","type":"RC"},{"code":"73523","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":63.390,"maximum":63.390,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":63.390,"methodology":"fee schedule"}]}]},{"description":"COMPLICATED PEPTIC ULCER WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"125","type":"RC"},{"code":"382","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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"}]}]},{"description":"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC ","code_information":[{"code":"142","type":"RC"},{"code":"626","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Repositioning of previously implanted subcutaneous implantable defibrillator electrode ","code_information":[{"code":"33273","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":13370.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":9999.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":11331.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":13370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC 3 Day Stay","code_information":[{"code":"123","type":"RC"},{"code":"577","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH 2 Day Stay","code_information":[{"code":"155","type":"RC"},{"code":"408","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC 2 Day Stay","code_information":[{"code":"114","type":"RC"},{"code":"516","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"122","type":"RC"},{"code":"413","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Drug metabolism (warfarin drug response), targeted sequence analysis (ie, CYP2C9, CYP4F2, VKORC1, rs12777823) ","code_information":[{"code":"0030U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":134.130,"maximum":134.130,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":134.130,"methodology":"fee schedule"}]}]},{"description":"AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC 4 Day Stay","code_information":[{"code":"157","type":"RC"},{"code":"476","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Footrest, lower extension tube, replacement only, each ","code_information":[{"code":"K0043","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":23.490,"maximum":58.250,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":24.170,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":23.970,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":25.170,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":23.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":23.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":23.970,"methodology":"fee schedule"},{"payer_name":"Cigna 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"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":6682.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":6682.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":6348.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":7862.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":4598.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC ","code_information":[{"code":"116","type":"RC"},{"code":"917","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"PULMONARY EDEMA AND RESPIRATORY FAILURE Pediatric","code_information":[{"code":"189","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":20415.790,"maximum":26250.800,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":20415.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":22958.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":22958.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":24605.370,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26250.800,"methodology":"fee schedule"}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC ","code_information":[{"code":"132","type":"RC"},{"code":"280","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"101","type":"RC"},{"code":"730","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (List separately in addition to code for primary procedure) ","code_information":[{"code":"480","type":"RC"},{"code":"57267","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH CC ","code_information":[{"code":"0D160ZA","type":"ICD"},{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17541.000,"maximum":33041.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":33041.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":25493.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":25493.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":24223.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":29992.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":17541.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":26065.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"TESTES PROCEDURES WITH CC/MCC ","code_information":[{"code":"711","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1275.000,"maximum":4488.000,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":1275.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4488.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $552131.00, reimbursement will be $6139 per diem instead of the contracted rate."}]}]},{"description":"EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT 2 Day Stay","code_information":[{"code":"120","type":"RC"},{"code":"927","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"SALIVARY GLAND PROCEDURES 4 Day Stay","code_information":[{"code":"126","type":"RC"},{"code":"139","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Haptoglobin; quantitative ","code_information":[{"code":"309","type":"RC"},{"code":"83010","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.780,"maximum":43.790,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":43.790,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":43.790,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.580,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":10.780,"methodology":"fee schedule"}]}]},{"description":"Laryngoscopy, flexible fiberoptic, with injection into vocal cord(s), therapeutic, including diagnostic laryngoscopy, if performed ","code_information":[{"code":"360","type":"RC"},{"code":"C9742","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2434.000,"maximum":5055.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"}]}]},{"description":"Repair and reconstruction, finger, volar plate, interphalangeal joint ","code_information":[{"code":"26548","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":595.000,"maximum":5069.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5069.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3911.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3911.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3716.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4601.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2692.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":1120.920,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1197.100,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1197.100,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1197.100,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1197.100,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":1077.390,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":595.000,"methodology":"case rate"}]}]},{"description":"MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"117","type":"RC"},{"code":"583","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Injection, aripiprazole, intramuscular, 0.25 mg ","code_information":[{"code":"636","type":"RC"},{"code":"J0400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.540,"maximum":0.540,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.540,"methodology":"fee schedule"}]}]},{"description":"Revision, open, arteriovenous fistula; with thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure) ","code_information":[{"code":"36833","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2080.790,"maximum":12087.980,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8686.800,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":10847.010,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":10847.010,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":11490.470,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12087.980,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5851.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2080.790,"methodology":"fee schedule"}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT 4 Day Stay","code_information":[{"code":"147","type":"RC"},{"code":"499","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES 4 Day Stay","code_information":[{"code":"150","type":"RC"},{"code":"279","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"157","type":"RC"},{"code":"257","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"INFLAMMATORY BOWEL DISEASE WITH CC ","code_information":[{"code":"160","type":"RC"},{"code":"386","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Cochlear device implantation, with or without mastoidectomy ","code_information":[{"code":"480","type":"RC"},{"code":"69930","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12167.000,"maximum":12167.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":12167.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC ","code_information":[{"code":"127","type":"RC"},{"code":"510","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace ","code_information":[{"code":"490","type":"RC"},{"code":"63075","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15732.530,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11305.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14954.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15732.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9124.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"}]}]},{"description":"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC ","code_information":[{"code":"128","type":"RC"},{"code":"629","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 3 Day Stay","code_information":[{"code":"118","type":"RC"},{"code":"330","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC Adult","code_information":[{"code":"659","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":49006.000,"maximum":65525.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":49006.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 20.4% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":55530.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 23.1% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":65525.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 27.3% of billable gross charges instead of the contracted rate."}]}]},{"description":"MAJOR HEAD AND NECK PROCEDURES WITH MCC 4 Day Stay","code_information":[{"code":"140","type":"MS-DRG"},{"code":"156","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"124","type":"RC"},{"code":"395","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"133","type":"RC"},{"code":"272","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC ","code_information":[{"code":"064","type":"MS-DRG"},{"code":"114","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC 3 Day Stay","code_information":[{"code":"139","type":"RC"},{"code":"233","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC ","code_information":[{"code":"10E0XZZ","type":"ICD"},{"code":"150","type":"RC"},{"code":"796","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1422.000,"maximum":2678.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":2678.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1964.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":2433.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1422.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "}]}]},{"description":"HEADACHES WITHOUT MCC 4 Day Stay","code_information":[{"code":"103","type":"MS-DRG"},{"code":"152","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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"}]}]},{"description":"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC Pediatric","code_information":[{"code":"179","type":"MS-DRG"},{"code":"203","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":28756.000,"maximum":38450.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":28756.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":32585.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":38450.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material ","code_information":[{"code":"402","type":"RC"},{"code":"72141","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":202.450,"maximum":675.460,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":675.460,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":675.460,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":202.450,"methodology":"fee schedule"}]}]},{"description":"Synovectomy, carpometacarpal joint ","code_information":[{"code":"26130","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":7199.490,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"Magnetoencephalography (MEG), recording and analysis; 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"}]}]},{"description":"DENTAL AND ORAL DISEASES WITH CC ","code_information":[{"code":"111","type":"RC"},{"code":"158","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Destruction of lesion of cornea by cryotherapy, photocoagulation or thermocauterization ","code_information":[{"code":"480","type":"RC"},{"code":"65450","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC 3 Day Stay","code_information":[{"code":"160","type":"RC"},{"code":"604","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Brain imaging, less than 4 static views; ","code_information":[{"code":"322","type":"RC"},{"code":"78600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":184.040,"maximum":568.420,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":568.420,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":568.420,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":184.040,"methodology":"fee schedule"}]}]},{"description":"PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE Pediatric","code_information":[{"code":"143","type":"RC"},{"code":"175","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":21486.000,"maximum":28730.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":21486.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":24347.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28730.000,"methodology":"case rate"}]}]},{"description":"Donor cardiectomy-pneumonectomy (including cold preservation) ","code_information":[{"code":"33930","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":14713.170,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10733.560,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":13098.590,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":13098.590,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13905.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14713.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE 2 Day Stay","code_information":[{"code":"129","type":"RC"},{"code":"318","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Blepharoplasty, upper eyelid; with excessive skin weighting down lid ","code_information":[{"code":"15823","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":678.000,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":730.280,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":779.910,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":779.910,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":779.910,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":779.910,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":701.920,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":678.000,"methodology":"case rate"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC ","code_information":[{"code":"138","type":"RC"},{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC 3 Day Stay","code_information":[{"code":"138","type":"RC"},{"code":"206","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"MAJOR BLADDER PROCEDURES WITH MCC 2 Day Stay","code_information":[{"code":"100","type":"RC"},{"code":"653","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC 3 Day Stay","code_information":[{"code":"101","type":"RC"},{"code":"729","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES 3 Day Stay","code_information":[{"code":"131","type":"RC"},{"code":"769","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"MAJOR MALE PELVIC PROCEDURES WITH CC/MCC ","code_information":[{"code":"110","type":"RC"},{"code":"707","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"LIVER TRANSPLANT WITHOUT MCC ","code_information":[{"code":"006","type":"MS-DRG"},{"code":"149","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Capsulodesis, metacarpophalangeal joint; 3 or 4 digits ","code_information":[{"code":"26518","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3350.610,"maximum":15732.530,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11305.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14954.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15732.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":3350.610,"methodology":"fee schedule"}]}]},{"description":"CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WI 4 Day Stay","code_information":[{"code":"023","type":"MS-DRG"},{"code":"145","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7938.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative 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"}]}]},{"description":"Computed tomography, thoracic spine; with contrast material ","code_information":[{"code":"342","type":"RC"},{"code":"72129","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":179.960,"maximum":685.500,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":685.500,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":685.500,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":179.960,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of metacarpal fracture, with manipulation, with external fixation, each bone ","code_information":[{"code":"26607","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":7199.490,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":3537.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2993.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"Neothelium 4l, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"636","type":"RC"},{"code":"Q4388","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WIT 4 Day Stay","code_information":[{"code":"154","type":"RC"},{"code":"497","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Radical resection of tumor, radial head or neck ","code_information":[{"code":"24152","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2573.700,"maximum":15732.530,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11305.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14954.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15732.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2573.700,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); 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"}]}]},{"description":"Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of left ","code_information":[{"code":"344","type":"RC"},{"code":"75573","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.950,"maximum":1169.010,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1169.010,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1169.010,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":183.950,"methodology":"fee schedule"}]}]},{"description":"Transcortin (cortisol binding globulin) ","code_information":[{"code":"84449","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.970,"maximum":65.750,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":18.150,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":16.330,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":18.000,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":18.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":41.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":50.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":50.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":53.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":18.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":18.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":18.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":56.520,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":49.140,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":55.810,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":65.750,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":18.000,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":18.000,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":18.000,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":18.000,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":18.000,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":35.640,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":15.570,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":36.000,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":53.990,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":18.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":18.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":18.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":18.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":18.000,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":18.000,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":19.620,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":16.630,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":43.740,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":16.630,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":16.630,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":16.630,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":37.800,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":42.300,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":18.900,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":18.900,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":19.080,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":19.080,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":19.080,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":19.080,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":19.080,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":18.900,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":27.900,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":18.900,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":18.900,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":18.900,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":14.970,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":19.480,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":18.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":18.360,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":21.600,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":17.640,"methodology":"fee schedule"}]}]},{"description":"LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC 3 Day Stay","code_information":[{"code":"155","type":"RC"},{"code":"417","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Drainage of abscess of palate, uvula ","code_information":[{"code":"361","type":"RC"},{"code":"42000","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":93.970,"maximum":5841.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":110.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":384.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":480.590,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":480.590,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":509.100,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":535.570,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":93.970,"methodology":"fee schedule"}]}]},{"description":"Xwrap 2.0, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"343","type":"RC"},{"code":"Q4402","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC 2 Day Stay","code_information":[{"code":"143","type":"RC"},{"code":"406","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC ","code_information":[{"code":"373","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1275.000,"maximum":3060.000,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":1275.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3060.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $552131.00, reimbursement will be $6139 per diem instead of the contracted rate."}]}]},{"description":"Biliary endoscopy, percutaneous via T-tube or other tract; with biopsy, single or multiple ","code_information":[{"code":"47553","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":482.000,"maximum":4100.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":4100.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3162.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3162.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3004.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":3720.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2176.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":1186.090,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1266.690,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1266.690,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1266.690,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1266.690,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":1140.020,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":482.000,"methodology":"case rate"}]}]},{"description":"SKIN GRAFTS FOR INJURIES WITH CC/MCC ","code_information":[{"code":"164","type":"RC"},{"code":"904","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC ","code_information":[{"code":"143","type":"RC"},{"code":"236","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"MALIGNANT BREAST DISORDERS WITH MCC 3 Day Stay","code_information":[{"code":"124","type":"RC"},{"code":"597","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC ","code_information":[{"code":"658","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10956.100,"maximum":10956.100,"payers_information":[{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":10956.100,"methodology":"fee schedule"}]}]},{"description":"INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"110","type":"RC"},{"code":"352","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"UNCOMPLICATED PEPTIC ULCER WITHOUT MCC 4 Day Stay","code_information":[{"code":"152","type":"RC"},{"code":"384","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Oncology (Bladder), analysis of 10 protein biomarkers by immunoassays, urine, diagnostic algorithm reported as a risk score for probability of rapid recurrence of recurrent or persistent cancer follow ","code_information":[{"code":"0367U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":902.180,"maximum":902.180,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":902.180,"methodology":"fee schedule"}]}]},{"description":"Excision, tumor, soft tissue of leg or ankle area, subfascial (eg, intramuscular); less than 5 cm ","code_information":[{"code":"27619","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2434.000,"maximum":2434.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2434.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Level VI - Surgical pathology, gross and microscopic examination Bone resection Breast, mastectomy - with regional lymph nodes Colon, segmental resection for tumor Colon, total resection Esophagus, pa ","code_information":[{"code":"312","type":"RC"},{"code":"88309","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":656.150,"maximum":1100.790,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1100.790,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1100.790,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":656.150,"methodology":"fee schedule"}]}]},{"description":"Exome (eg, unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained exome sequence (eg, updated knowledge or unrelated condition/syndrome) ","code_information":[{"code":"309","type":"RC"},{"code":"81417","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":320.000,"maximum":902.400,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":902.400,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":902.400,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":320.000,"methodology":"fee schedule"}]}]},{"description":"CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC 3 Day Stay","code_information":[{"code":"073","type":"MS-DRG"},{"code":"147","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY ","code_information":[{"code":"131","type":"RC"},{"code":"173","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"CATH PLACEMENT, ANGIOGRAPHY ","code_information":[{"code":"499","type":"RC"},{"code":"93508","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of infected graft; abdomen ","code_information":[{"code":"35907","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery ","code_information":[{"code":"361","type":"RC"},{"code":"59618","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":31655.510,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":23093.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":28181.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":28181.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":29918.620,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":31655.510,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"}]}]},{"description":"REVISION OF HIP OR KNEE REPLACEMENT WITH MCC ","code_information":[{"code":"153","type":"RC"},{"code":"466","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"COMPLEX AORTIC ARCH PROCEDURES ","code_information":[{"code":"158","type":"RC"},{"code":"209","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Hepatitis B and Haemophilus influenzae type b vaccine (Hib-HepB), for intramuscular use ","code_information":[{"code":"636","type":"RC"},{"code":"90748","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":82.120,"maximum":82.120,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":82.120,"methodology":"fee schedule"}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"147","type":"RC"},{"code":"759","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Gastric emptying imaging study (eg, solid, liquid, or both); with small bowel and colon transit, multiple days ","code_information":[{"code":"619","type":"RC"},{"code":"78266","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":436.240,"maximum":436.240,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":436.240,"methodology":"fee schedule"}]}]},{"description":"MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"132","type":"RC"},{"code":"508","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE ","code_information":[{"code":"159","type":"RC"},{"code":"464","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"COMPLICATED PEPTIC ULCER WITH MCC 3 Day Stay","code_information":[{"code":"117","type":"RC"},{"code":"380","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Open treatment of tibial shaft fracture (with or without fibular fracture), with plate/screws, with or without cerclage ","code_information":[{"code":"27758","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":595.000,"maximum":7470.900,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5069.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3911.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3911.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3716.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4601.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2692.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":6995.480,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":7470.900,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":7470.900,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":7470.900,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":7470.900,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":6723.810,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":595.000,"methodology":"case rate"}]}]},{"description":"Preparation of fecal microbiota for instillation, including assessment of donor specimen ","code_information":[{"code":"44705","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DIGESTIVE MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"135","type":"RC"},{"code":"376","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. 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"}]}]},{"description":"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH 3 Day Stay","code_information":[{"code":"003","type":"MS-DRG"},{"code":"112","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Trimethylamine/trimethylamine N-oxide (TMA/TMAO) profile, tandem mass spectrometry (MS/MS), urine, with algorithmic analysis and interpretive report ","code_information":[{"code":"0256U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":159.950,"maximum":159.950,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":159.950,"methodology":"fee schedule"}]}]},{"description":"INTRAOCULAR PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"117","type":"MS-DRG"},{"code":"128","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Quantitative computed tomography (CT) tissue characterization, including interpretation and report, obtained without concurrent CT examination of any structure contained in previously acquired diagnos ","code_information":[{"code":"0721T","type":"CPT"},{"code":"351","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1463.630,"maximum":1463.630,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1463.630,"methodology":"fee schedule"}]}]},{"description":"OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"093","type":"MS-DRG"},{"code":"146","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Ultrasound, nerve(s) and accompanying structures throughout their entire anatomic course in one extremity, comprehensive, including real-time cine imaging with image documentation, per extremity ","code_information":[{"code":"612","type":"RC"},{"code":"76883","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":59.650,"maximum":59.650,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":59.650,"methodology":"fee schedule"}]}]},{"description":"ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC 4 Day Stay","code_information":[{"code":"130","type":"RC"},{"code":"288","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Replacement, aortic valve; by translocation of autologous pulmonary valve with allograft replacement of pulmonary valve (Ross procedure) ","code_information":[{"code":"33413","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":43258.290,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":31557.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":38511.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":38511.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":40884.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":43258.290,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC 2 Day Stay","code_information":[{"code":"085","type":"MS-DRG"},{"code":"134","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC 2 Day Stay","code_information":[{"code":"139","type":"RC"},{"code":"660","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Injection, levothyroxine sodium (fresenius kabi), not therapeutically equivalent to j0650, 10 mcg ","code_information":[{"code":"891","type":"RC"},{"code":"J0651","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":11.450,"maximum":11.450,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.450,"methodology":"fee schedule"}]}]},{"description":"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EX ","code_information":[{"code":"149","type":"RC"},{"code":"456","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC 3 Day Stay","code_information":[{"code":"128","type":"RC"},{"code":"177","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC ","code_information":[{"code":"153","type":"RC"},{"code":"940","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Tongue base suspension, permanent suture technique ","code_information":[{"code":"369","type":"RC"},{"code":"41512","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":12756.890,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9167.500,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11447.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11447.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12126.320,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12756.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"}]}]},{"description":"Direct skilled nursing services of a registered nurse (rn) in the home health or hospice setting, each 15 minutes ","code_information":[{"code":"369","type":"RC"},{"code":"G0299","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay ºEIA», enzyme-linked immunosorbent assay ºELISA», fluorescence immunoassay ºFIA», immunochemiluminometric assay ºIMC ","code_information":[{"code":"87467","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.590,"maximum":61.530,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":25.540,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":9.370,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":25.320,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":26.590,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":34.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":41.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":41.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":44.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":25.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":25.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":25.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":47.260,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":25.320,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":25.320,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":25.320,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":25.320,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":25.320,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":50.130,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":8.940,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":50.640,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":25.320,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":25.320,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":25.320,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":25.320,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":25.320,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":25.320,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":27.600,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":9.550,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":61.530,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":9.550,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":9.550,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":9.550,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":53.170,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":59.500,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":26.590,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":26.590,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":26.840,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":26.840,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":26.840,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":26.840,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":26.840,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":26.590,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":39.250,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":26.590,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":26.590,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":26.590,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":8.590,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":27.400,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":25.320,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":25.830,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":30.380,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":24.810,"methodology":"fee schedule"}]}]},{"description":"COMPLICATED PEPTIC ULCER WITH MCC ","code_information":[{"code":"112","type":"RC"},{"code":"380","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"OTITIS MEDIA AND URI WITH MCC Pediatric","code_information":[{"code":"123","type":"RC"},{"code":"152","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15645.000,"maximum":20919.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":15645.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":17728.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":20919.000,"methodology":"case rate"}]}]},{"description":"OTITIS MEDIA AND URI WITHOUT MCC 4 Day Stay","code_information":[{"code":"133","type":"RC"},{"code":"153","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"123","type":"RC"},{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Radiologic examination, spine, lumbosacral; complete, including bending views, minimum of 6 views ","code_information":[{"code":"614","type":"RC"},{"code":"72114","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":63.390,"maximum":63.390,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":63.390,"methodology":"fee schedule"}]}]},{"description":"Extended culture of oocyte(s)/embryo(s), 4-7 days ","code_information":[{"code":"302","type":"RC"},{"code":"89272","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":656.150,"maximum":656.150,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":656.150,"methodology":"fee schedule"}]}]},{"description":"Transcervical ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency ","code_information":[{"code":"367","type":"RC"},{"code":"58580","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"VENTRICULAR SHUNT PROCEDURES WITH CC ","code_information":[{"code":"032","type":"MS-DRG"},{"code":"133","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC ","code_information":[{"code":"101","type":"RC"},{"code":"244","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Repair blood vessel with vein graft; lower extremity ","code_information":[{"code":"35256","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3529.000,"maximum":6646.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":6646.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":5129.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":5129.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4874.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":6034.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3529.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC ","code_information":[{"code":"157","type":"RC"},{"code":"726","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Tuberculosis test, cell mediated immunity antigen response measurement; enumeration of gamma interferon-producing T-cells in cell suspension ","code_information":[{"code":"309","type":"RC"},{"code":"86481","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":85.680,"maximum":282.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":282.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":282.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":100.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":85.680,"methodology":"fee schedule"}]}]},{"description":"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NEC ","code_information":[{"code":"004","type":"MS-DRG"},{"code":"167","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Computed tomography, upper extremity; with contrast material(s) ","code_information":[{"code":"73201","type":"CPT"},{"code":"922","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":214.040,"maximum":214.040,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":214.040,"methodology":"fee schedule"}]}]},{"description":"Anoscopy; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) ","code_information":[{"code":"46600","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ABLATE HEART DYSRHYTHM FOCUS ","code_information":[{"code":"499","type":"RC"},{"code":"93652","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"APPENDIX PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"143","type":"RC"},{"code":"399","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Magnetic resonance angiography, neck; without contrast material(s) ","code_information":[{"code":"612","type":"RC"},{"code":"70547","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":229.380,"maximum":3090.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3090.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2385.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2385.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":2265.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":2807.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1641.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":517.790,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":229.380,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views ","code_information":[{"code":"618","type":"RC"},{"code":"73502","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":48.050,"maximum":48.050,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":48.050,"methodology":"fee schedule"}]}]},{"description":"Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular ","code_information":[{"code":"33207","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10949.000,"maximum":10949.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":10949.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"TESTES PROCEDURES WITH CC/MCC Adult","code_information":[{"code":"711","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":29738.000,"maximum":39764.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":29738.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 20.4% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":33698.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 23.1% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":39764.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 27.3% of billable gross charges instead of the contracted rate."}]}]},{"description":"CERVICAL SPINAL FUSION WITH MCC ","code_information":[{"code":"164","type":"RC"},{"code":"471","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s) ","code_information":[{"code":"614","type":"RC"},{"code":"72149","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":288.330,"maximum":3090.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3090.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2385.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2385.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":2265.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":2807.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1641.000,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":828.270,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":288.330,"methodology":"fee schedule"}]}]},{"description":"Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, including all imaging guidance, image documentation, and all associated radiological supervision a ","code_information":[{"code":"360","type":"RC"},{"code":"36572","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":240.100,"maximum":7037.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":282.470,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1191.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1488.000,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1488.000,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1576.280,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1658.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case 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logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health 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","code_information":[{"code":"33985","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12018.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5109.970,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6235.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6235.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6620.220,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7004.550,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative 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"}]}]},{"description":"INFLAMMATORY BOWEL DISEASE WITH CC ","code_information":[{"code":"110","type":"RC"},{"code":"386","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC 3 Day Stay","code_information":[{"code":"135","type":"RC"},{"code":"820","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Repair of nonunion, scaphoid carpal (navicular) bone, with or without radial styloidectomy (includes obtaining graft and necessary fixation) ","code_information":[{"code":"25440","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15732.530,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":3027.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11305.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14117.400,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14954.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15732.530,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":7799.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6326.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11460.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2573.700,"methodology":"fee schedule"}]}]},{"description":"OSTEOMYELITIS WITH CC 4 Day Stay","code_information":[{"code":"140","type":"RC"},{"code":"540","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"MR safety implant positioning and/or immobilization under supervision of physician or other qualified health care professional, including application of physical protections to secure implanted medica ","code_information":[{"code":"610","type":"RC"},{"code":"76019","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":133.650,"maximum":133.650,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":133.650,"methodology":"fee schedule"}]}]},{"description":" Radiology - Therapeutic and/or Chemotherapy Administration Radiation Therapy  ","code_information":[{"code":"333","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2430.000,"maximum":2430.000,"payers_information":[{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2430.000,"methodology":"case rate"}]}]},{"description":"Incision (eg, osteomyelitis or bone abscess), leg or ankle ","code_information":[{"code":"27607","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":5487.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"110","type":"RC"},{"code":"804","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Removal of intact breast implant ","code_information":[{"code":"19328","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1034.050,"maximum":15410.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5725.850,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7149.740,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7149.740,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7573.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7967.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3339.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1034.050,"methodology":"fee schedule"}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH CC ","code_information":[{"code":"132","type":"RC"},{"code":"300","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Arthrodesis, carpometacarpal joint, digit, other than thumb, each; ","code_information":[{"code":"26843","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Human Platelet Antigen 2 genotyping (HPA-2), GP1BA (glycoprotein Ib ºplatelet», alpha polypeptide ºGPIba») (eg, neonatal alloimmune thrombocytopenia ºNAIT», post-transfusion purpura), gene analysis, c ","code_information":[{"code":"301","type":"RC"},{"code":"81106","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":104.710,"maximum":425.510,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":425.510,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":425.510,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":122.220,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":104.710,"methodology":"fee schedule"}]}]},{"description":"Removal of subcutaneous implantable defibrillator electrode ","code_information":[{"code":"33272","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ENDOCRINE DISORDERS WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"134","type":"RC"},{"code":"645","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"ABORTION WITHOUT D&C ","code_information":[{"code":"135","type":"RC"},{"code":"779","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC 2 Day Stay","code_information":[{"code":"126","type":"RC"},{"code":"940","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH CC ","code_information":[{"code":"0DL73CZ","type":"ICD"},{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2950.000,"maximum":2950.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2950.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"Repair of scleral staphyloma with graft ","code_information":[{"code":"480","type":"RC"},{"code":"66225","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3041.000,"maximum":3041.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revision of total hip arthroplasty; both components, with or without autograft or allograft ","code_information":[{"code":"27134","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":86009.250,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":62694.670,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":76605.050,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":76605.050,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":81307.150,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":86009.250,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":42583.000,"methodology":"case rate"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":29056.000,"methodology":"case rate"}]}]},{"description":"Anterior thoracic vertebral body tethering, including thoracoscopy, when performed; 8 or more vertebral segments High Cost Surgery","code_information":[{"code":"22837","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2369.000,"maximum":2369.000,"payers_information":[{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":2369.000,"methodology":"case rate"}]}]},{"description":"PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC ","code_information":[{"code":"118","type":"RC"},{"code":"273","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"CONNECTIVE TISSUE DISORDERS WITH CC 4 Day Stay","code_information":[{"code":"131","type":"RC"},{"code":"546","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC ","code_information":[{"code":"100","type":"RC"},{"code":"10D07Z4","type":"ICD"},{"code":"807","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1422.000,"maximum":2678.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":2678.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1964.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":2433.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1422.000,"methodology":"case rate","additional_payer_notes":"Days 3+. 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"}]}]},{"description":"OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"072","type":"MS-DRG"},{"code":"116","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. 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multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8349.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"WOUND DEBRIDEMENTS FOR INJURIES WITH MCC 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"}]}]},{"description":"EXTRAOCULAR PROCEDURES EXCEPT ORBIT ","code_information":[{"code":"115","type":"MS-DRG"},{"code":"120","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NEC 4 Day Stay","code_information":[{"code":"004","type":"MS-DRG"},{"code":"159","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Consultation and report on referred slides prepared elsewhere ","code_information":[{"code":"312","type":"RC"},{"code":"88321","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":33.840,"maximum":287.160,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":287.160,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":287.160,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":33.840,"methodology":"fee schedule"}]}]},{"description":"Arteriovenous anastomosis, open; by forearm vein transposition High Cost Surgery","code_information":[{"code":"36820","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2369.000,"maximum":2369.000,"payers_information":[{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":2369.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":2369.000,"methodology":"case rate"}]}]},{"description":"TRANSURETHRAL PROSTATECTOMY WITH CC/MCC ","code_information":[{"code":"138","type":"RC"},{"code":"713","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3941.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Galactose-1-phosphate uridyl transferase; quantitative ","code_information":[{"code":"310","type":"RC"},{"code":"82775","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.050,"maximum":73.350,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":73.350,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":73.350,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":18.050,"methodology":"fee schedule"}]}]},{"description":"Biopsy of salivary gland; needle ","code_information":[{"code":"42400","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":61.780,"maximum":5055.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":446.670,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":545.010,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":545.010,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":578.790,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":612.570,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":2946.000,"methodology":"case 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","code_information":[{"code":"636","type":"RC"},{"code":"Q4320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"Helmet, protective, soft, prefabricated, includes all components and accessories ","code_information":[{"code":"A8000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":235.250,"maximum":340.300,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":247.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":302.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":302.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":322.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":340.300,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":235.250,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":235.250,"methodology":"fee schedule"}]}]},{"description":"Non-pneumatic compression controller without calibrated gradient pressure ","code_information":[{"code":"E0681","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":128.270,"maximum":318.060,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":132.000,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":130.890,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":137.430,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":130.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":130.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":130.890,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":130.890,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":130.890,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":130.890,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":130.890,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":130.890,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":259.160,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":261.780,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":130.890,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":130.890,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":130.890,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":130.890,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":130.890,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":130.890,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":142.670,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":318.060,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":274.870,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":137.430,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":137.430,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":138.740,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":138.740,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":138.740,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":138.740,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":138.740,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":137.430,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":202.880,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":137.430,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":137.430,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":137.430,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":130.890,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":130.890,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":133.510,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":157.070,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":128.270,"methodology":"fee schedule"}]}]},{"description":"OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC 2 Day Stay","code_information":[{"code":"113","type":"RC"},{"code":"206","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC 2 Day Stay","code_information":[{"code":"126","type":"RC"},{"code":"723","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC ","code_information":[{"code":"10D07Z7","type":"ICD"},{"code":"160","type":"RC"},{"code":"807","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1422.000,"maximum":2678.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":2678.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1964.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":2433.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1422.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC ","code_information":[{"code":"116","type":"RC"},{"code":"717","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC ","code_information":[{"code":"923","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2900.420,"maximum":2900.420,"payers_information":[{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":2900.420,"methodology":"fee schedule"}]}]},{"description":"SEIZURES WITH MCC 2 Day Stay","code_information":[{"code":"100","type":"MS-DRG"},{"code":"124","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"MAJOR BLADDER PROCEDURES WITH MCC ","code_information":[{"code":"113","type":"RC"},{"code":"653","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"DILATION PROSTATIC URETHRA ","code_information":[{"code":"490","type":"RC"},{"code":"52510","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 3 Day Stay","code_information":[{"code":"100","type":"RC"},{"code":"981","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC 3 Day Stay","code_information":[{"code":"128","type":"RC"},{"code":"657","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Radical resection of sternum ","code_information":[{"code":"21630","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive ","code_information":[{"code":"Q0249","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":7.570,"maximum":17.740,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_percentage":8.07,"standard_charge_algorithm":"Reimbursement will be 8.07% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":13.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":13.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15.240,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":13.200,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":15.030,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":17.740,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_percentage":15.84,"standard_charge_algorithm":"Reimbursement will be 15.84% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_percentage":16.00,"standard_charge_algorithm":"Reimbursement will be 16% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_percentage":8.72,"standard_charge_algorithm":"Reimbursement will be 8.72% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":19.44,"standard_charge_algorithm":"Reimbursement will be 19.44% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_percentage":16.80,"standard_charge_algorithm":"Reimbursement will be 16.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_percentage":8.48,"standard_charge_algorithm":"Reimbursement will be 8.48% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_percentage":8.48,"standard_charge_algorithm":"Reimbursement will be 8.48% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_percentage":8.48,"standard_charge_algorithm":"Reimbursement will be 8.48% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_percentage":8.48,"standard_charge_algorithm":"Reimbursement will be 8.48% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_percentage":8.48,"standard_charge_algorithm":"Reimbursement will be 8.48% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior","plan_name":"HIX","standard_charge_percentage":12.40,"standard_charge_algorithm":"Reimbursement will be 12.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_percentage":8.40,"standard_charge_algorithm":"Reimbursement will be 8.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":7.570,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":8.00,"standard_charge_algorithm":"Reimbursement will be 8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_percentage":8.16,"standard_charge_algorithm":"Reimbursement will be 8.16% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_percentage":9.60,"standard_charge_algorithm":"Reimbursement will be 9.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_percentage":7.84,"standard_charge_algorithm":"Reimbursement will be 7.84% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE ","code_information":[{"code":"116","type":"RC"},{"code":"465","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Surgery of intracranial arteriovenous malformation; supratentorial, simple ","code_information":[{"code":"61680","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3061.000,"maximum":5765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5765.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4449.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4226.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5233.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3061.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"112","type":"RC"},{"code":"983","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"115","type":"RC"},{"code":"976","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Upper extremity addition, lift assist for elbow ","code_information":[{"code":"L6635","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":265.430,"maximum":2915.590,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":273.150,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":270.850,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":284.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":270.850,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":270.850,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":270.850,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":270.850,"methodology":"fee 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"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcript ","code_information":[{"code":"301","type":"RC"},{"code":"87507","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":357.100,"maximum":1451.030,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1451.030,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1451.030,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":357.100,"methodology":"fee schedule"}]}]},{"description":"RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC 3 Day Stay","code_information":[{"code":"135","type":"RC"},{"code":"814","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Corneal relaxing incision for correction of surgically induced astigmatism ","code_information":[{"code":"369","type":"RC"},{"code":"65772","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":359.700,"maximum":8444.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":423.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1525.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1904.450,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1904.450,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":2017.430,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2122.330,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":2613.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":2251.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2527.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2650.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3649.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":359.700,"methodology":"fee schedule"}]}]},{"description":"Immunodiffusion; gel diffusion, qualitative (Ouchterlony), each antigen or antibody ","code_information":[{"code":"314","type":"RC"},{"code":"86331","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.260,"maximum":41.710,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":41.710,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":41.710,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":10.260,"methodology":"fee schedule"}]}]},{"description":"TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC 3 Day Stay","code_information":[{"code":"086","type":"MS-DRG"},{"code":"148","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"BENIGN PROSTATIC HYPERTROPHY WITH MCC ","code_information":[{"code":"164","type":"RC"},{"code":"725","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH CC 2 Day Stay","code_information":[{"code":"140","type":"RC"},{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"OTHER DISORDERS OF THE EYE WITHOUT MCC 3 Day Stay","code_information":[{"code":"125","type":"MS-DRG"},{"code":"138","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC ","code_information":[{"code":"110","type":"RC"},{"code":"760","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC 2 Day Stay","code_information":[{"code":"155","type":"RC"},{"code":"723","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"TRANSURETHRAL PROCEDURES WITH CC 4 Day Stay","code_information":[{"code":"112","type":"RC"},{"code":"669","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC 2 Day Stay","code_information":[{"code":"020","type":"MS-DRG"},{"code":"157","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"100","type":"RC"},{"code":"566","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. 4 Day Stay","code_information":[{"code":"149","type":"RC"},{"code":"826","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"SKIN ULCERS WITH CC 3 Day Stay","code_information":[{"code":"101","type":"RC"},{"code":"593","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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with removal of ureteral calculus ","code_information":[{"code":"481","type":"RC"},{"code":"52320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1226.380,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5705.040,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7123.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":7123.750,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7546.350,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7938.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":7367.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8349.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9851.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1226.380,"methodology":"fee schedule"}]}]},{"description":"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC ","code_information":[{"code":"144","type":"RC"},{"code":"760","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Endovascular repair of thoracic aorta, including pre-procedure sizing and device selection, nonselective catheterization(s), all associated radiological supervision and interpretation; by deployment o ","code_information":[{"code":"33880","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic ","code_information":[{"code":"22222","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":23331.340,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":17020.700,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":20771.020,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":20771.020,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":22051.180,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":23331.340,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":8778.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15581.000,"methodology":"case rate"}]}]},{"description":"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC ","code_information":[{"code":"133","type":"RC"},{"code":"578","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC ","code_information":[{"code":"127","type":"RC"},{"code":"557","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Revision of total hip arthroplasty; both components, with or without autograft or allograft ","code_information":[{"code":"27134","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":42583.000,"maximum":42583.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":42583.000,"methodology":"case rate"}]}]},{"description":"OTHER HEART ASSIST SYSTEM IMPLANT 2 Day Stay","code_information":[{"code":"151","type":"RC"},{"code":"215","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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"}]}]},{"description":"Anabolic steroids; 1 or 2 ","code_information":[{"code":"319","type":"RC"},{"code":"80327","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.000,"maximum":59.050,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":59.050,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":59.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":19.000,"methodology":"fee schedule"}]}]},{"description":"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC 2 Day Stay","code_information":[{"code":"098","type":"MS-DRG"},{"code":"144","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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"}]}]},{"description":"Radiologic examination, hand; 2 views ","code_information":[{"code":"612","type":"RC"},{"code":"73120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":32.040,"maximum":32.040,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":32.040,"methodology":"fee schedule"}]}]},{"description":"OSTEOMYELITIS WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"148","type":"RC"},{"code":"541","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"PAIN SYNDROME; M > 37.15 ","code_information":[{"code":"024","type":"RC"},{"code":"B1601","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":17921.710,"maximum":19751.930,"payers_information":[{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":19751.930,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":19027.090,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":17921.710,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY NEOPLASMS WITH CC 3 Day Stay","code_information":[{"code":"159","type":"RC"},{"code":"181","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":7.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":6.510,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":15.040,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":22.580,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":7.520,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":7.520,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":7.520,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":7.520,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":7.520,"methodology":"fee 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schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":17.670,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":7.900,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":7.900,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":7.970,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":7.970,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":7.970,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":7.970,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":7.970,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":7.900,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":11.660,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":7.900,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":7.900,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":7.900,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":6.260,"methodology":"fee schedule"},{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":8.140,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":7.520,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":7.670,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":9.020,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":7.370,"methodology":"fee schedule"}]}]},{"description":"SEPTIC ARTHRITIS WITH MCC ","code_information":[{"code":"548","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.000,"maximum":34863.600,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":19757.950,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_dollar":16219.560,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_dollar":20274.450,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":20018.190,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":21019.100,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Averde Health","plan_name":"COMM","standard_charge_percentage":33.00,"standard_charge_algorithm":"Reimbursement will be 33% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":27119.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":34106.850,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":34106.850,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":34486.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":20018.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":20018.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":20018.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":34863.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":19818.010,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":19818.010,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":19818.010,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":19818.010,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":19818.010,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":28339.750,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":26352.920,"methodology":"fee schedule"},{"payer_name":"First Health","plan_name":"Exclusive","standard_charge_dollar":2258.000,"methodology":"per diem"},{"payer_name":"First Health","plan_name":"NonExclusive","standard_charge_dollar":2346.000,"methodology":"per diem"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":28626.010,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":62.00,"standard_charge_algorithm":"Reimbursement will be 62% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"HealthSmart Preferred Care","plan_name":"SOUTHTEXASISDRATES","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":19117.370,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":29284.030,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":19117.370,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":19117.370,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":19117.370,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":19117.370,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":29284.030,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":26907.090,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":21819.830,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":30598.970,"methodology":"fee schedule"},{"payer_name":"MultiPlan","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":30057.310,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":24039.710,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":21019.100,"methodology":"fee schedule"},{"payer_name":"PPO Next/ Medical Control","plan_name":"COMMPPO","standard_charge_percentage":75.00,"standard_charge_algorithm":"Reimbursement will be 75% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":21019.100,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":20418.550,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":20418.550,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":20418.550,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":20418.550,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":20418.550,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":21419.460,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":31028.190,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":21019.100,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":21019.100,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":21019.100,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.000,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.000,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":20018.190,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":21019.100,"methodology":"fee schedule"},{"payer_name":"Texas Workforce Commission","plan_name":"WORKERSCOMP","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":20018.190,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6450.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $552131.00, reimbursement will be $6139 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalBenefitPlan","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":19797.990,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":16.10,"standard_charge_algorithm":"Reimbursement will be 16.1% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":21619.650,"methodology":"fee schedule"},{"payer_name":"USA Managed Care","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":20098.260,"methodology":"fee schedule"}]}]},{"description":"APPENDIX PROCEDURES WITH MCC 3 Day Stay","code_information":[{"code":"101","type":"RC"},{"code":"397","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Injection, hyaluronidase, ovine, preservative free, per 1000 usp units ","code_information":[{"code":"J3472","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":268.710,"maximum":1878.210,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":268.710,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":305.920,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":361.040,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1878.210,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1878.210,"methodology":"fee schedule"}]}]},{"description":"Injection, risperidone (rykindo), 0.5 mg ","code_information":[{"code":"343","type":"RC"},{"code":"J2801","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":21.500,"maximum":21.500,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":21.500,"methodology":"fee schedule"}]}]},{"description":"NON-MALIGNANT BREAST DISORDERS WITH CC/MCC ","code_information":[{"code":"115","type":"RC"},{"code":"600","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"VENTRICULAR SHUNT PROCEDURES WITH CC 4 Day Stay","code_information":[{"code":"032","type":"MS-DRG"},{"code":"152","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"138","type":"RC"},{"code":"905","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"MAJOR MULTIPLE TRAUMA NO BRAIN OR SPINAL CORD INJU ","code_information":[{"code":"138","type":"RC"},{"code":"A1701","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":15397.370,"maximum":16783.130,"payers_information":[{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":15397.370,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":15397.370,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":16783.130,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":16167.230,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":15705.310,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":15705.310,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":15705.310,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":15705.310,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":15705.310,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":16167.230,"methodology":"fee schedule"}]}]},{"description":"Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with stress imaging ","code_information":[{"code":"483","type":"RC"},{"code":"C9763","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":426.360,"maximum":426.360,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":426.360,"methodology":"fee schedule"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH MCC ","code_information":[{"code":"169","type":"RC"},{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Thoracoscopy, surgical; with resection of thymus, unilateral or bilateral ","code_information":[{"code":"32673","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":16331.440,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11914.130,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14539.280,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14539.280,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":15435.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16331.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Injection, phenobarbital sodium (sezaby), 1 mg ","code_information":[{"code":"J2561","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2.250,"maximum":3.560,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":2.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":2.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":2.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3.090,"methodology":"fee 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"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3025.000,"methodology":"per diem","additional_payer_notes":"Days 11+. 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"}]}]},{"description":"ALLERGIC REACTIONS WITHOUT MCC 2 Day Stay","code_information":[{"code":"143","type":"RC"},{"code":"916","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"URETHRAL STRICTURE 3 Day Stay","code_information":[{"code":"143","type":"RC"},{"code":"697","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Internal neurolysis, requiring use of operating microscope (List separately in addition to code for neuroplasty) (Neuroplasty includes external neurolysis) ","code_information":[{"code":"480","type":"RC"},{"code":"64727","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5841.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC ","code_information":[{"code":"100","type":"RC"},{"code":"872","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT ","code_information":[{"code":"008","type":"MS-DRG"},{"code":"121","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Insertion of indwelling tunneled pleural catheter with cuff ","code_information":[{"code":"32550","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1535.980,"maximum":13127.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3589.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2768.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2768.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":2630.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":3257.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1904.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Allegian Health","plan_name":"CHOICE","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":1598.050,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":13127.000,"methodology":"case rate"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1706.650,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1706.650,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1706.650,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1706.650,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":1535.980,"methodology":"fee schedule"}]}]},{"description":"Antibody; lymphocytic choriomeningitis ","code_information":[{"code":"307","type":"RC"},{"code":"86727","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.030,"maximum":44.810,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":44.810,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":44.810,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.870,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":11.030,"methodology":"fee schedule"}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"111","type":"RC"},{"code":"195","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"128","type":"RC"},{"code":"407","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"PENIS PROCEDURES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"146","type":"RC"},{"code":"710","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC 3 Day Stay","code_information":[{"code":"145","type":"RC"},{"code":"522","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"SKIN DEBRIDEMENT WITH CC 4 Day Stay","code_information":[{"code":"133","type":"RC"},{"code":"571","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETER ","code_information":[{"code":"151","type":"RC"},{"code":"219","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Determination of central c-v hemodynamics (non-imaging) (eg, ejection fraction with probe technique) with or without pharmacologic intervention or exercise, single or multiple determinations ","code_information":[{"code":"351","type":"RC"},{"code":"78414","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":179.610,"maximum":179.610,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":179.610,"methodology":"fee schedule"}]}]},{"description":"Injection, dexamethasone, intravitreal implant, 0.1 mg ","code_information":[{"code":"636","type":"RC"},{"code":"J7312","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":337.490,"maximum":337.490,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":337.490,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation ","code_information":[{"code":"76813","type":"CPT"},{"code":"921","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":109.020,"maximum":109.020,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":109.020,"methodology":"fee schedule"}]}]},{"description":"OTHER HEPATOBILIARY OR PANCREAS O.R. 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"}]}]},{"description":"Cholecystoenterostomy; direct ","code_information":[{"code":"361","type":"RC"},{"code":"47720","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15589.980,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11373.220,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":13879.180,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":13879.180,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14734.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15589.980,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MC 2 Day Stay","code_information":[{"code":"148","type":"RC"},{"code":"739","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"DIABETES WITHOUT CC/MCC 4 Day Stay","code_information":[{"code":"100","type":"RC"},{"code":"639","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC ","code_information":[{"code":"115","type":"RC"},{"code":"740","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH 3 Day Stay","code_information":[{"code":"128","type":"RC"},{"code":"408","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"ACUTE LEUKEMIA WITH MCC ","code_information":[{"code":"101","type":"RC"},{"code":"834","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Gross pulpal debridement ","code_information":[{"code":"361","type":"RC"},{"code":"D3221","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HEART FAILURE AND SHOCK WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"150","type":"RC"},{"code":"293","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; 3 cm or greater ","code_information":[{"code":"25071","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":13370.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":9999.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":11331.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":13370.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 4 Day Stay","code_information":[{"code":"115","type":"RC"},{"code":"955","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC 3 Day Stay","code_information":[{"code":"156","type":"RC"},{"code":"856","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC A 3 Day Stay","code_information":[{"code":"063","type":"MS-DRG"},{"code":"130","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"COMPLICATED PEPTIC ULCER WITH CC 4 Day Stay","code_information":[{"code":"164","type":"RC"},{"code":"381","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C ","code_information":[{"code":"10D07Z3","type":"ICD"},{"code":"142","type":"RC"},{"code":"768","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1422.000,"maximum":2678.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":2678.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2068.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1964.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":2433.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1422.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "}]}]},{"description":"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETER 3 Day Stay","code_information":[{"code":"143","type":"RC"},{"code":"221","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC ","code_information":[{"code":"156","type":"RC"},{"code":"802","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":700.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s) ","code_information":[{"code":"341","type":"RC"},{"code":"71271","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.020,"maximum":109.020,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":109.020,"methodology":"fee schedule"}]}]},{"description":"HEART FAILURE AND SHOCK WITH CC 4 Day Stay","code_information":[{"code":"113","type":"RC"},{"code":"292","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC ","code_information":[{"code":"114","type":"RC"},{"code":"285","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Gastrectomy, partial, distal; with formation of intestinal pouch ","code_information":[{"code":"43634","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":28670.900,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":20916.020,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":25524.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":25524.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":27097.770,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":28670.900,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"OTHER DISORDERS OF NERVOUS SYSTEM WITH CC ","code_information":[{"code":"092","type":"MS-DRG"},{"code":"128","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC ","code_information":[{"code":"094","type":"MS-DRG"},{"code":"169","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Allegian Health","plan_name":"COMM","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"AMPUTATION, NON-LOWER EXTREMITY; M=12-37 ","code_information":[{"code":"024","type":"RC"},{"code":"D1103","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":26868.920,"maximum":29612.860,"payers_information":[{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":29612.860,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":28526.150,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":26868.920,"methodology":"fee schedule"}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH MCC ","code_information":[{"code":"157","type":"RC"},{"code":"299","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Inj., lumoxiti, 0.01 mg ","code_information":[{"code":"09305","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":23.390,"maximum":23.390,"payers_information":[{"payer_name":"TriWest Health Alliance","plan_name":"TRCR","standard_charge_dollar":23.390,"methodology":"fee schedule"}]}]},{"description":"OTHER O.R. 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"}]}]},{"description":"Level I - Surgical pathology, gross examination only ","code_information":[{"code":"311","type":"RC"},{"code":"88300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.670,"maximum":44.980,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":44.980,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":44.980,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":24.670,"methodology":"fee schedule"}]}]},{"description":"COAGULATION AND PLATELET DISORDERS ","code_information":[{"code":"6612","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4791.180,"maximum":5582.590,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":5582.590,"methodology":"fee schedule"},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":4984.770,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":5081.560,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":5081.560,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":5081.560,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":5081.560,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":5055.150,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":5055.150,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":5055.150,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":5055.150,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":5055.150,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":4791.180,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":4936.370,"methodology":"fee schedule"}]}]},{"description":"Capsular contracture release (eg, Sever type procedure) ","code_information":[{"code":"23020","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":5487.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"VENTRICULAR SHUNT PROCEDURES WITH CC 2 Day Stay","code_information":[{"code":"032","type":"MS-DRG"},{"code":"154","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"VIRAL ILLNESS WITH MCC 2 Day Stay","code_information":[{"code":"164","type":"RC"},{"code":"865","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"CAROTID ARTERY STENT PROCEDURES WITH MCC 4 Day Stay","code_information":[{"code":"034","type":"MS-DRG"},{"code":"147","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH 3 Day Stay","code_information":[{"code":"142","type":"RC"},{"code":"618","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Oncology (pancreatic cancer), multiplex immonoassay of C5, C4, Cystatin C, factor B, osteoprotegerin, gelsolin, IGFBP3, CA125 and multiplex electrochemiluminescent immunoassay for CA19-9, serum, diagn ","code_information":[{"code":"0342U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":47.650,"maximum":2179.710,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":904.620,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":941.850,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":47.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":58.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":58.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":61.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":65.340,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":1776.060,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":1794.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":977.730,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":2179.710,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":1883.700,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2107.950,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":941.850,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":941.850,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":950.820,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":950.820,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":950.820,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":950.820,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":950.820,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":941.850,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":1390.350,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":941.850,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":941.850,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":941.850,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":897.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":914.940,"methodology":"fee schedule"},{"payer_name":"Universal Health Care","plan_name":"MCR","standard_charge_dollar":1076.400,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":879.060,"methodology":"fee schedule"}]}]},{"description":"PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ A 2 Day Stay","code_information":[{"code":"101","type":"RC"},{"code":"321","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA 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"}]}]},{"description":"Open treatment of nasal fracture; uncomplicated ","code_information":[{"code":"21325","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12635.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1119.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4950.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6181.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6181.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6548.230,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6888.730,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":951.370,"methodology":"fee schedule"}]}]},{"description":"VIRAL ILLNESS WITH MCC 4 Day Stay","code_information":[{"code":"134","type":"RC"},{"code":"865","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES ","code_information":[{"code":"142","type":"RC"},{"code":"213","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"REPAIR ARTERIAL BLOCKAGE ","code_information":[{"code":"35450","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SEPTIC ARTHRITIS WITH CC 3 Day Stay","code_information":[{"code":"120","type":"RC"},{"code":"549","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Combined endoscopic catheterization of the biliary and pancreatic ductal systems, radiological supervision and interpretation ","code_information":[{"code":"342","type":"RC"},{"code":"74330","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":569.840,"maximum":569.840,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":569.840,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":569.840,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC 2 Day Stay","code_information":[{"code":"121","type":"RC"},{"code":"756","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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M < 27.85 ","code_information":[{"code":"C2004","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":27897.690,"maximum":30672.860,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":30205.460,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":30672.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":29212.240,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":28920.120,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":28920.120,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":28920.120,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":28920.120,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":28920.120,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":27897.690,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":27897.690,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":27897.690,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":27897.690,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":27897.690,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":29212.240,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":29212.240,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":29212.240,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":30672.860,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":29212.240,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":29329.090,"methodology":"fee schedule"}]}]},{"description":"Antinuclear antibodies (ANA); ","code_information":[{"code":"312","type":"RC"},{"code":"86038","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.360,"maximum":42.070,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":42.070,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":42.070,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":10.360,"methodology":"fee schedule"}]}]},{"description":"ACUTE LEUKEMIA WITHOUT CC/MCC ","code_information":[{"code":"123","type":"RC"},{"code":"836","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Spleen imaging only, with or without vascular flow ","code_information":[{"code":"351","type":"RC"},{"code":"78185","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":172.110,"maximum":172.110,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":172.110,"methodology":"fee schedule"}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC 4 Day Stay","code_information":[{"code":"126","type":"RC"},{"code":"740","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), humerus ","code_information":[{"code":"24140","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15410.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":1373.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":5849.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":4988.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":8328.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":7455.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15410.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"MINOR SKIN DISORDERS WITH MCC 2 Day Stay","code_information":[{"code":"119","type":"RC"},{"code":"606","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); second interspace, lumbar (List separately in addition to code ","code_information":[{"code":"22860","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":13988.660,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10205.020,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12453.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12453.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13221.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13988.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"SALIVARY GLAND PROCEDURES ","code_information":[{"code":"139","type":"MS-DRG"},{"code":"143","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Smear, primary source with interpretation; complex special stain (eg, trichrome, iron hemotoxylin) for ova and parasites ","code_information":[{"code":"312","type":"RC"},{"code":"87209","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.400,"maximum":62.580,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":62.580,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":62.580,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":15.400,"methodology":"fee schedule"}]}]},{"description":"Venous anastomosis, open; splenorenal, proximal ","code_information":[{"code":"367","type":"RC"},{"code":"37180","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":7037.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s) ","code_information":[{"code":"615","type":"RC"},{"code":"71271","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.020,"maximum":109.020,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":109.020,"methodology":"fee schedule"}]}]},{"description":"OTHER DISORDERS OF THE EYE WITHOUT MCC 3 Day Stay","code_information":[{"code":"125","type":"MS-DRG"},{"code":"129","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"ANGINA PECTORIS 2 Day Stay","code_information":[{"code":"146","type":"RC"},{"code":"311","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"HPlacement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, or dissection; initial vessel ","code_information":[{"code":"34825","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":5841.000,"payers_information":[{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cm ","code_information":[{"code":"17283","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":125.650,"maximum":5841.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":854.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1042.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1042.830,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1107.460,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1172.100,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare 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"}]}]},{"description":"Heart transplant, with or without recipient cardiectomy ","code_information":[{"code":"33945","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2333.000,"maximum":65913.380,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":48085.190,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":58680.230,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":58680.230,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":62296.810,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":65913.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Infectious agent detection and identification, targeted sequence analysis (16S and 18S rRNA genes) with drug-resistance gene ","code_information":[{"code":"0112U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":356.130,"maximum":356.130,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":356.130,"methodology":"fee schedule"}]}]},{"description":"Bone marrow, smear interpretation ","code_information":[{"code":"304","type":"RC"},{"code":"85097","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":252.780,"maximum":656.150,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":252.780,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":252.780,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":656.150,"methodology":"fee schedule"}]}]},{"description":"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC 3 Day Stay","code_information":[{"code":"167","type":"RC"},{"code":"493","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Reconstruction, toe(s); polydactyly ","code_information":[{"code":"28344","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5173.780,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6460.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6843.630,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7199.490,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":6315.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7157.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8444.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":4807.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":3041.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":7227.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5830.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung biopsy(s), single lobe ","code_information":[{"code":"31628","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":5487.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC ","code_information":[{"code":"067","type":"MS-DRG"},{"code":"164","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, quantification ","code_information":[{"code":"87557","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.630,"maximum":156.520,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":43.200,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_percentage":35.40,"standard_charge_algorithm":"Reimbursement will be 35.4% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_percentage":33.70,"standard_charge_algorithm":"Reimbursement will be 33.7% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_percentage":41.60,"standard_charge_algorithm":"Reimbursement will be 41.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_percentage":26.50,"standard_charge_algorithm":"Reimbursement will be 26.5% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":38.870,"methodology":"fee schedule"},{"payer_name":"Allegian Health","plan_name":"MGMCR","standard_charge_dollar":42.840,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":44.980,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":98.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":119.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":119.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":127.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":42.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":42.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":42.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":134.520,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":116.970,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":132.840,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":156.520,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":42.840,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":42.840,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":42.840,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":42.840,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":42.840,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":84.820,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Driscoll Children's Health Plan","plan_name":"MCD","standard_charge_dollar":37.070,"methodology":"fee schedule"},{"payer_name":"Focus Healthcare","plan_name":"PPO","standard_charge_dollar":85.680,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":128.500,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":42.840,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":42.840,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":42.840,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":42.840,"methodology":"fee 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"}]}]},{"description":"Closed treatment of radial and ulnar shaft fractures; with manipulation ","code_information":[{"code":"25565","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":636.360,"maximum":5487.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2561.690,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3198.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3198.720,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3388.480,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3564.680,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":4104.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4650.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5487.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":636.360,"methodology":"fee schedule"}]}]},{"description":"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH 4 Day Stay","code_information":[{"code":"003","type":"MS-DRG"},{"code":"135","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. 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PROCEDURES FOR OBESITY WITH CC ","code_information":[{"code":"0DB60ZZ","type":"ICD"},{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":26065.000,"maximum":26065.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":26065.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC 3 Day Stay","code_information":[{"code":"119","type":"RC"},{"code":"867","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.6 to 1.0 cm ","code_information":[{"code":"17261","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":330.240,"maximum":5841.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":330.240,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":412.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":412.360,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":436.820,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":459.540,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"}]}]},{"description":"Closure of multiple ventricular septal defects; with pulmonary valvotomy or infundibular resection (acyanotic) ","code_information":[{"code":"33676","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":27439.790,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":20017.900,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":24428.620,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":24428.620,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":25934.200,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":27439.790,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, spine, lumbosacral; 2 or 3 views ","code_information":[{"code":"614","type":"RC"},{"code":"72100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":40.900,"maximum":40.900,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":40.900,"methodology":"fee schedule"}]}]},{"description":"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC 3 Day Stay","code_information":[{"code":"154","type":"RC"},{"code":"863","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC A Adult","code_information":[{"code":"062","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":32521.000,"maximum":43484.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":32521.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 20.4% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":36851.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 23.1% of billable gross charges instead of the contracted rate."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":43484.000,"methodology":"case rate","additional_payer_notes":" If billable gross charges exceed threshold of $803641.00, reimbursement will be 27.3% of billable gross charges instead of the contracted rate."}]}]},{"description":"OTHER CARDIOTHORACIC PROCEDURES WITH MCC 3 Day Stay","code_information":[{"code":"137","type":"RC"},{"code":"228","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Cerebrospinal fluid flow, imaging (not including introduction of material); shunt evaluation ","code_information":[{"code":"340","type":"RC"},{"code":"78645","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":324.450,"maximum":1101.150,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1001.490,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1001.490,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1101.150,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":324.450,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC 4 Day Stay","code_information":[{"code":"101","type":"RC"},{"code":"722","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC ","code_information":[{"code":"127","type":"RC"},{"code":"439","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"ABORTION WITHOUT D&C Pediatric","code_information":[{"code":"779","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17633.410,"maximum":22673.190,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":17633.410,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":19829.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":19829.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":21252.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":22673.190,"methodology":"fee schedule"}]}]},{"description":"Frenuloplasty ","code_information":[{"code":"362","type":"RC"},{"code":"D7963","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5055.000,"maximum":5055.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC ","code_information":[{"code":"001","type":"MS-DRG"},{"code":"02WA0QZ","type":"ICD"}],"standard_charges":[{"setting":"inpatient","minimum":294418.000,"maximum":294418.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":294418.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 20. "}]}]},{"description":"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC ","code_information":[{"code":"128","type":"RC"},{"code":"626","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":350.000,"maximum":350.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":350.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Manometric studies through ureterostomy or indwelling ureteral catheter ","code_information":[{"code":"50686","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":62.020,"maximum":5841.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":415.960,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":507.550,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":507.550,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":539.010,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":570.470,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":1672.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":2940.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":62.020,"methodology":"fee schedule"}]}]},{"description":"Lymphatics and lymph nodes imaging ","code_information":[{"code":"352","type":"RC"},{"code":"78195","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":355.120,"maximum":355.120,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":355.120,"methodology":"fee schedule"}]}]},{"description":"Esketamine, nasal spray, 1 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J0013","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":29.500,"maximum":29.500,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":29.500,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, thoracic spine; without contrast material ","code_information":[{"code":"401","type":"RC"},{"code":"72128","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.020,"maximum":540.730,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":540.730,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":540.730,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":109.020,"methodology":"fee schedule"}]}]},{"description":"Oncology (prostate), mRNA, gene expression profiling by real-time RT-PCR of 17 genes (12 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm report as a risk scor ","code_information":[{"code":"0047U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3873.000,"maximum":3873.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3873.000,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS 4 Day Stay","code_information":[{"code":"118","type":"RC"},{"code":"207","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":400.000,"maximum":400.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":400.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC 2 Day Stay","code_information":[{"code":"101","type":"RC"},{"code":"650","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Infectious disease (bacterial or viral RTI) pathogen-specific DNA & RN A,21 targets,incl severe acute respiratory syndrome coronavirus 2(SARS- CoV-2), amplified probe technique,including multiple ","code_information":[{"code":"0225U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":416.620,"maximum":416.620,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":416.620,"methodology":"fee schedule"}]}]},{"description":"ATHEROSCLEROSIS WITH MCC 2 Day Stay","code_information":[{"code":"133","type":"RC"},{"code":"302","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":600.000,"maximum":600.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":600.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac); each additional lesion with separate injection (List separately in addition to code for primary procedure) ","code_information":[{"code":"611","type":"RC"},{"code":"76979","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":171.090,"maximum":171.090,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":171.090,"methodology":"fee schedule"}]}]},{"description":"SPINAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"030","type":"MS-DRG"},{"code":"147","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":700.000,"maximum":5571.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5571.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":4299.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":4084.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":5056.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2958.000,"methodology":"per diem"},{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":700.000,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Colostomy or skin level cecostomy; ","code_information":[{"code":"361","type":"RC"},{"code":"44320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":16252.120,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11856.260,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14468.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14468.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":15360.390,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16252.120,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":12018.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5055.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":948.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"}]}]},{"description":"INFECTIOUS AND PARASITIC DISEASES WITH O.R. 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","code_information":[{"code":"57270","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4807.000,"maximum":12635.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":7835.010,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":9561.370,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":9561.370,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":10150.660,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10739.940,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5963.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7037.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Curative 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rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12635.000,"methodology":"case rate"}]}]},{"description":"INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC 3 Day Stay","code_information":[{"code":"113","type":"RC"},{"code":"352","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":500.000,"maximum":500.000,"payers_information":[{"payer_name":"USA Managed Care","plan_name":"CHIP","standard_charge_dollar":500.000,"methodology":"per diem","additional_payer_notes":"Days 1 - 3. 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