{"hospital_name":"VALLEY REGIONAL MEDICAL CENTER","last_updated_on":"2026-03-01","version":"3.0.0","location_name":["VALLEY REGIONAL MEDICAL CENTER"],"hospital_address":["100 A ALTON GLOOR, BROWNSVILLE, TX, 78526"],"license_information":{"license_number":"19","state":"TX"},"type_2_npi":["1043267701"],"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":"Jose Hernandez"},"standard_charge_information":[{"description":"MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC Pediatric","code_information":[{"code":"142","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":21249.920,"maximum":43507.840,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":21249.920,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $751194.00, charges over the threshold will be paid at 14.6% of billable gross charges in addition to the contracteded rate."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":32816.270,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $751194.00, charges over the threshold will be paid at 21.5% of billable gross charges in addition to the contracteded rate."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":32816.270,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $751194.00, charges over the threshold will be paid at 21.5% of billable gross charges in addition to the contracteded rate."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":38162.860,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $751194.00, charges over the threshold will be paid at 22.8% of billable gross charges in addition to the contracteded rate."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":43507.840,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $751194.00, charges over the threshold will be paid at 24% of billable gross charges in addition to the contracteded rate."}]}]},{"description":"Intentional replantation ","code_information":[{"code":"367","type":"RC"},{"code":"D3470","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":12814.000,"maximum":12814.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC ","code_information":[{"code":"137","type":"RC"},{"code":"415","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Radiologic examination, ankle; 2 views ","code_information":[{"code":"350","type":"RC"},{"code":"73600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":33.410,"maximum":33.410,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":33.410,"methodology":"fee schedule"}]}]},{"description":"Collagenase, clost hist i ","code_information":[{"code":"1340","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":75.520,"maximum":159.060,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":76.390,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":79.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":75.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":75.750,"methodology":"fee 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","code_information":[{"code":"362","type":"RC"},{"code":"58565","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9999.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radical resection of tumor, radius or ulna ","code_information":[{"code":"25170","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":15732.530,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10169.310,"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":13878.120,"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":13878.120,"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":14835.240,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"ENDOCRINE DISORDERS WITH CC ","code_information":[{"code":"131","type":"RC"},{"code":"644","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Valvotomy, pulmonary valve, closed heart, via pulmonary artery ","code_information":[{"code":"33471","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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":"MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants ","code_information":[{"code":"312","type":"RC"},{"code":"81297","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":182.750,"maximum":2211.920,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":2211.920,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":2211.920,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":182.750,"methodology":"fee schedule"}]}]},{"description":"Nocturnal penile tumescence and/or rigidity test ","code_information":[{"code":"481","type":"RC"},{"code":"54250","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":60.740,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":60.740,"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":89.450,"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":89.450,"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":94.850,"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":100.120,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula); with revision of arterial or venous graft ","code_information":[{"code":"35876","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2080.790,"maximum":26535.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":7813.520,"methodology":"fee 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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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":26535.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2080.790,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":14093.000,"methodology":"case rate"}]}]},{"description":"Removal or revision of sling for stress incontinence (eg, fascia or synthetic) ","code_information":[{"code":"490","type":"RC"},{"code":"57287","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15613.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4246.770,"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":5795.590,"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":5795.590,"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":6195.290,"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":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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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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 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; 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further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":5816.000,"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":7253.780,"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":8680.750,"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 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Zero instances of this service in the last 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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":17359.710,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":58494.000,"methodology":"case rate"}]}]},{"description":"Injection, estradiol valerate, up to 10 mg ","code_information":[{"code":"343","type":"RC"},{"code":"J1380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":12.290,"maximum":12.290,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.290,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":12.290,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, esophagus, including scout chest radiograph(s) and delayed image(s), when performed; 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second level (List separately in ","code_information":[{"code":"22870","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1573.000,"maximum":3384.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3384.000,"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":2600.000,"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":2600.000,"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":2528.000,"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":3057.000,"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":1573.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Strabismus surgery on patient with previous eye surgery or injury that did not involve the extraocular muscles (List separately in addition to code for primary procedure) ","code_information":[{"code":"481","type":"RC"},{"code":"67331","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1022.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"MAJOR SKIN DISORDERS WITHOUT MCC Pediatric","code_information":[{"code":"143","type":"RC"},{"code":"596","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13380.000,"maximum":17891.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":13380.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":15162.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":17891.000,"methodology":"case rate"}]}]},{"description":"Cont epidur inject-lumb ","code_information":[{"code":"480","type":"RC"},{"code":"62279","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":"EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"117","type":"RC"},{"code":"983","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Closure of single ventricular septal defect, with or without patch; with pulmonary valvotomy or 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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":"PPO","standard_charge_dollar":25597.780,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Interdental wiring, for condition other than fracture ","code_information":[{"code":"21497","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC ","code_information":[{"code":"10D07Z3","type":"ICD"},{"code":"111","type":"RC"},{"code":"807","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2344.000,"maximum":5046.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5046.000,"methodology":"case rate","additional_payer_notes":"Days 3+. 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"}]}]},{"description":"Injection procedure for myelography and/or computed tomography, lumbar ","code_information":[{"code":"62284","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1022.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"In situ hybridization (eg, FISH), per specimen; 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logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":5198.000,"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":5198.000,"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":5055.000,"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":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (ovarian), serum, analysis of 39 glycoproteins by liquid chromatography with tandem mass spectrometry (LC-MS/MS) in multiple reaction ","code_information":[{"code":"0577U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":246.920,"maximum":246.920,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":246.920,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":246.920,"methodology":"fee schedule"}]}]},{"description":"OSTEOMYELITIS, SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS ","code_information":[{"code":"3442","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4490.900,"maximum":5211.250,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":5211.250,"methodology":"fee 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","code_information":[{"code":"22226","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1022.000,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2996.940,"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":4411.530,"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":4411.530,"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":4674.620,"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":4933.890,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Tapentadol ","code_information":[{"code":"303","type":"RC"},{"code":"80372","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.830,"maximum":122.570,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":122.570,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":122.570,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":10.830,"methodology":"fee schedule"}]}]},{"description":"Injection, epidural, of blood or clot patch ","code_information":[{"code":"62273","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":282.060,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1062.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1450.120,"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":1450.120,"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":1550.120,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":4352.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":282.060,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":2310.000,"methodology":"case rate"}]}]},{"description":"Infectious disease (bacterial or viral), biochemical assays, tumor necrosis factor related apoptosis-inducing ligand interferon gamma induced protein-10, and C-reactive protein, serum, algorithm repor ","code_information":[{"code":"0351U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":260.500,"maximum":260.500,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":260.500,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":260.500,"methodology":"fee schedule"}]}]},{"description":"Removal of sutures or staples requiring anesthesia (ie, general anesthesia, moderate sedation) ","code_information":[{"code":"15851","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":66.840,"maximum":12814.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":78.640,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":353.730,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":520.940,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":520.940,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":552.390,"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":583.110,"methodology":"fee schedule","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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":66.840,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MC ","code_information":[{"code":"739","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.000,"maximum":86728.840,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":30030.750,"methodology":"fee schedule"},{"payer_name":"Affiliated Healthcare","plan_name":"COMM","standard_charge_percentage":68.00,"standard_charge_algorithm":"Reimbursement will be 68% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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_dollar":31947.600,"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":48928.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":60086.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":60086.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":68774.640,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":30426.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":30426.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":30426.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":77458.940,"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":84.00,"standard_charge_algorithm":"Reimbursement will be 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":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":30122.030,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":30122.030,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":30122.030,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":30122.030,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":30122.030,"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":43074.500,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":48898.050,"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":"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":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":"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":29057.110,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":86728.840,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":29057.110,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":29057.110,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":29057.110,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":29057.110,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":86728.840,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":49926.320,"methodology":"fee schedule"},{"payer_name":"MCM Maxcare","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":"Molina","plan_name":"MGMCR","standard_charge_dollar":33164.660,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":48245.980,"methodology":"fee schedule"},{"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":45685.070,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":44605.860,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":31339.080,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":31947.600,"methodology":"fee schedule"},{"payer_name":"ProNet PPO","plan_name":"PPO","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":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":31034.820,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":31034.820,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":31034.820,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":31034.820,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":31034.820,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":32556.130,"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":47160.750,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":31947.600,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":31947.600,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":31947.600,"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":30426.290,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":31947.600,"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":"Total E&P Mexico","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":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":30426.290,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":46053.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 9. "},{"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":30091.600,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":28.70,"standard_charge_algorithm":"Reimbursement will be 28.7% 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":"United","plan_name":"SmallGroup","standard_charge_dollar":24841.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 9. "},{"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":31034.820,"methodology":"fee schedule"}]}]},{"description":"Antibody; parvovirus ","code_information":[{"code":"314","type":"RC"},{"code":"86747","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.880,"maximum":192.470,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":192.470,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":192.470,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":12.880,"methodology":"fee schedule"}]}]},{"description":"Gastrointestinal endoscopic ultrasound, supervision and interpretation ","code_information":[{"code":"343","type":"RC"},{"code":"76975","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":112.550,"maximum":699.250,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":699.250,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":699.250,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":112.550,"methodology":"fee schedule"}]}]},{"description":"OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC ","code_information":[{"code":"141","type":"RC"},{"code":"394","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Laminectomy with rhizotomy; 1 or 2 segments ","code_information":[{"code":"490","type":"RC"},{"code":"63185","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":23368.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9415.810,"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":13860.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":13860.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14686.740,"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":15501.340,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":23368.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":12606.000,"methodology":"case rate"}]}]},{"description":"Venography, adrenal, unilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"619","type":"RC"},{"code":"75840","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":132.230,"maximum":132.230,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":132.230,"methodology":"fee schedule"}]}]},{"description":"Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar ","code_information":[{"code":"22214","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":26535.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":12293.830,"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":18096.640,"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":18096.640,"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":19175.870,"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":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":"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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":26535.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":14093.000,"methodology":"case rate"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH MCC ","code_information":[{"code":"0DN63ZZ","type":"ICD"},{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":19663.000,"maximum":42326.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":42326.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":32497.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":32497.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":31608.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":38231.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":19663.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH CC ","code_information":[{"code":"0D190ZA","type":"ICD"},{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13898.000,"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. "},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":13898.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Harvest of skin for tissue cultured skin autograft, 100 sq cm or less ","code_information":[{"code":"15040","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":760.800,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2758.660,"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":3764.760,"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":3764.760,"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":4024.400,"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":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 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rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":521.990,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"Estriol ","code_information":[{"code":"314","type":"RC"},{"code":"82677","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.720,"maximum":309.540,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":309.540,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":309.540,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":20.720,"methodology":"fee schedule"}]}]},{"description":"Strapping; Unna boot 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":326.360,"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":344.520,"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":12814.000,"methodology":"case 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this service in the last 15 months prior to posting. 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3361.370,"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":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 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logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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","code_information":[{"code":"21387","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":20821.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8245.900,"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":11253.230,"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":11253.230,"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":12029.310,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":20821.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":11042.000,"methodology":"case rate"}]}]},{"description":"CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC Pediatric","code_information":[{"code":"133","type":"RC"},{"code":"235","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":87501.000,"maximum":116997.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":87501.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":99150.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":116997.000,"methodology":"case rate"}]}]},{"description":"Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps ","code_information":[{"code":"360","type":"RC"},{"code":"43216","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":606.240,"maximum":13940.000,"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":2647.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3613.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3613.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3862.350,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Removal and replacement of permanent cardiac contractility modulation-defibrillation pulse generator only ","code_information":[{"code":"0923T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":15931.000,"maximum":59033.480,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":38158.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":52075.160,"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":52075.160,"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":55666.550,"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":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":29535.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":15931.000,"methodology":"case rate"}]}]},{"description":"Removal or revision of sling for male urinary incontinence (eg, fascia or synthetic) ","code_information":[{"code":"53442","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1573.000,"maximum":3384.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3384.000,"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":2600.000,"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":2600.000,"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":2528.000,"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":3057.000,"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":1573.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":2282.840,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2437.990,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":2437.990,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":2437.990,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":2437.990,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":2194.190,"methodology":"fee schedule"},{"payer_name":"USA MCO","plan_name":"CHIP","standard_charge_dollar":2216.350,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, infant hips, real time with imaging documentation; dynamic (requiring physician or other qualified health care professional manipulation) ","code_information":[{"code":"320","type":"RC"},{"code":"76885","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":82.520,"maximum":1071.010,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1071.010,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1071.010,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":82.520,"methodology":"fee 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logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arterial exposure with creation of graft conduit (eg, chimney graft) to facilitate arterial perfusion for ECMO/ECLS (List separately in addition to code for primary procedure) ","code_information":[{"code":"33987","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 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":19524.910,"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":20607.860,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Fetal scalp blood sampling 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":4690.720,"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":4690.720,"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":5014.210,"methodology":"fee schedule","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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1149.710,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1219.100,"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":1286.910,"methodology":"fee schedule","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":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":4352.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":2310.000,"methodology":"case rate"}]}]},{"description":"Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when performed ","code_information":[{"code":"400","type":"RC"},{"code":"78227","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":441.700,"maximum":4160.860,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":4160.860,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":4160.860,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":441.700,"methodology":"fee schedule"}]}]},{"description":"Amniotic fluid scan (spectrophotometric) ","code_information":[{"code":"301","type":"RC"},{"code":"82143","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.010,"maximum":96.960,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":96.960,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":96.960,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9.350,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":8.010,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9.350,"methodology":"fee schedule"}]}]},{"description":"EGFR (epidermal growth factor receptor) (eg, non-small cell lung cancer) gene analysis, common variants (eg, exon 19 LREA deletion, L858R, T790M, G719A, G719S, L861Q) ","code_information":[{"code":"307","type":"RC"},{"code":"81235","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":278.100,"maximum":3365.890,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":3365.890,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":3365.890,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":324.580,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":278.100,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":324.580,"methodology":"fee schedule"}]}]},{"description":"Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; cervical ","code_information":[{"code":"481","type":"RC"},{"code":"63015","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8778.000,"maximum":26535.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10169.310,"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":13878.120,"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":13878.120,"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":14835.240,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":26535.000,"methodology":"case 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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":"Tenolysis, flexor or extensor tendon, leg and/or ankle; multiple tendons (through separate incisionºs») ","code_information":[{"code":"27681","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transfer, toe-to-hand with microvascular anastomosis; other than great toe, single ","code_information":[{"code":"26553","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2993.000,"maximum":43836.580,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":26627.160,"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":39195.460,"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":39195.460,"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":41532.960,"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":43836.580,"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":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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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1640.380,"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":1731.630,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":198.750,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral ","code_information":[{"code":"29868","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":26535.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10169.310,"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":13878.120,"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":13878.120,"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":14835.240,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":26535.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":14093.000,"methodology":"case rate"}]}]},{"description":"TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC ","code_information":[{"code":"087","type":"MS-DRG"},{"code":"143","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL; WITH REMOVAL OF PARAVAGINAL TISSUE (RADICAL VAGINECTOMY) WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PARA-AORTIC LYMPH NODE SAMPLING (BIOPSY) ","code_information":[{"code":"369","type":"RC"},{"code":"57112","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":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC ","code_information":[{"code":"142","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"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":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Whole blood volume determination, including separate measurement of plasma volume and red cell volume (radiopharmaceutical volume-dilution technique) ","code_information":[{"code":"324","type":"RC"},{"code":"78122","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":97.470,"maximum":765.310,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":765.310,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":765.310,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":97.470,"methodology":"fee schedule"}]}]},{"description":"Cineradiography/videoradiography, except where specifically included ","code_information":[{"code":"76120","type":"CPT"},{"code":"924","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":"SKIN TISSUE REARRANGEMENT ","code_information":[{"code":"14300","type":"CPT"},{"code":"490","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":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of scapular fracture; with manipulation, with or without skeletal traction (with or without shoulder joint involvement) ","code_information":[{"code":"23575","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":587.110,"maximum":3384.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3384.000,"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":2600.000,"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":2600.000,"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":2528.000,"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":3057.000,"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":1573.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":610.830,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":652.340,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":652.340,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":652.340,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":652.340,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":587.110,"methodology":"fee schedule"},{"payer_name":"USA MCO","plan_name":"CHIP","standard_charge_dollar":593.040,"methodology":"fee schedule"}]}]},{"description":"REVISE ESOPHAGUS & STOMACH ","code_information":[{"code":"361","type":"RC"},{"code":"43326","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":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC ","code_information":[{"code":"420","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.000,"maximum":82475.670,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":28683.450,"methodology":"fee schedule"},{"payer_name":"Affiliated Healthcare","plan_name":"COMM","standard_charge_percentage":68.00,"standard_charge_algorithm":"Reimbursement will be 68% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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_dollar":30514.310,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 6. "},{"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":44993.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":55254.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":55254.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":63244.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":29061.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":29061.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":29061.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":71230.220,"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":84.00,"standard_charge_algorithm":"Reimbursement will be 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":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":28770.640,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":28770.640,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":28770.640,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":28770.640,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":28770.640,"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":41142.010,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":46500.100,"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":"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":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":"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":27753.490,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":82475.670,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":27753.490,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":27753.490,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":27753.490,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":27753.490,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":82475.670,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":47477.940,"methodology":"fee schedule"},{"payer_name":"MCM Maxcare","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":"Molina","plan_name":"MGMCR","standard_charge_dollar":31676.760,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":45880.010,"methodology":"fee schedule"},{"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":43635.470,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":42418.390,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":29933.090,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":30514.310,"methodology":"fee schedule"},{"payer_name":"ProNet PPO","plan_name":"PPO","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":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":29642.480,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":29642.480,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":29642.480,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":29642.480,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":29642.480,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":31095.540,"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":45044.940,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":30514.310,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":30514.310,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":30514.310,"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":29061.250,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":30514.310,"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":"Total E&P Mexico","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":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":29061.250,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":22000.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $658089.00, reimbursement will be $9450 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":28741.580,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":28.70,"standard_charge_algorithm":"Reimbursement will be 28.7% 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":"United","plan_name":"SmallGroup","standard_charge_dollar":19840.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $658089.00, reimbursement will be $5250 per diem instead of the contracted 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":29642.480,"methodology":"fee schedule"}]}]},{"description":"CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC Adult","code_information":[{"code":"275","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":89003.000,"maximum":119007.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":89003.000,"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":100854.000,"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":119007.000,"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":"Ultrasound bone density measurement and interpretation, peripheral site(s), any method ","code_information":[{"code":"76977","type":"CPT"},{"code":"924","type":"RC"}],"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":"Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material ","code_information":[{"code":"352","type":"RC"},{"code":"73721","type":"CPT"}],"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":"Treatment of humeral shaft fracture, with insertion of intramedullary implant, with or without cerclage and/or locking screws ","code_information":[{"code":"24516","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3145.000,"maximum":7397.210,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":6769.000,"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":5198.000,"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":5198.000,"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":5055.000,"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":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":6926.480,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":7397.210,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":7397.210,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":7397.210,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":7397.210,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":6657.490,"methodology":"fee schedule"},{"payer_name":"USA MCO","plan_name":"CHIP","standard_charge_dollar":6724.740,"methodology":"fee schedule"}]}]},{"description":"Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less ","code_information":[{"code":"15150","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":760.800,"maximum":12814.000,"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":2758.660,"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":3764.760,"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":3764.760,"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":4024.400,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":760.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC ","code_information":[{"code":"100","type":"RC"},{"code":"432","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Osteotomy, radius; distal third ","code_information":[{"code":"25350","type":"CPT"},{"code":"480","type":"RC"}],"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":"Ostectomy, complete excision; first metatarsal head ","code_information":[{"code":"28111","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":13940.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4653.660,"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":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6788.880,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"Phosphorus inorganic (phosphate); ","code_information":[{"code":"305","type":"RC"},{"code":"84100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.060,"maximum":60.660,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":60.660,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":60.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":4.060,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4.740,"methodology":"fee schedule"}]}]},{"description":"Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study ","code_information":[{"code":"402","type":"RC"},{"code":"93308","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":100.530,"maximum":100.530,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":100.530,"methodology":"fee schedule"}]}]},{"description":"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC Pediatric","code_information":[{"code":"405","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":75960.090,"maximum":155523.390,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":75960.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":117305.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":117305.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":136417.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":155523.390,"methodology":"fee schedule"}]}]},{"description":"Removal of foreign body, intraocular; from anterior chamber of eye or lens ","code_information":[{"code":"490","type":"RC"},{"code":"65235","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":912.020,"maximum":13940.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3437.160,"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":4690.720,"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":4690.720,"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":5014.210,"methodology":"fee schedule","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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":912.020,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"Cytopathology, smears, any other source; screening and interpretation ","code_information":[{"code":"300","type":"RC"},{"code":"88160","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":454.720,"maximum":454.720,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":454.720,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":454.720,"methodology":"fee schedule"}]}]},{"description":"Biopsy, muscle; deep ","code_information":[{"code":"20205","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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); for exploration, with or without biopsy ","code_information":[{"code":"67450","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15613.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5316.000,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7254.780,"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":7254.780,"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":7755.110,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":11962.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2080.790,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":6598.000,"methodology":"case rate"}]}]},{"description":"Injection, pegaspargase, per single dose vial 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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":32.60,"standard_charge_algorithm":"Reimbursement will be 32.6% 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":"Meritain","standard_charge_percentage":32.60,"standard_charge_algorithm":"Reimbursement will be 32.6% 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":"NewBusiness","standard_charge_percentage":31.70,"standard_charge_algorithm":"Reimbursement will be 31.7% 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":38.20,"standard_charge_algorithm":"Reimbursement will be 38.2% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":21.40,"standard_charge_algorithm":"Reimbursement will be 21.4% 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":24704.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":36268.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":36268.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":38546.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":40649.160,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":55426.920,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":63101.410,"methodology":"fee 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adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":9261.000,"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":9008.000,"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":10894.000,"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":5603.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":3227.760,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":3447.130,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":3447.130,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":3447.130,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":3447.130,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":3102.410,"methodology":"fee schedule"},{"payer_name":"USA MCO","plan_name":"CHIP","standard_charge_dollar":3133.750,"methodology":"fee schedule"}]}]},{"description":"MINOR SKIN DISORDERS WITHOUT MCC ","code_information":[{"code":"152","type":"RC"},{"code":"607","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Leucine aminopeptidase (LAP) ","code_information":[{"code":"319","type":"RC"},{"code":"83670","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.400,"maximum":117.280,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":117.280,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":117.280,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":8.400,"methodology":"fee schedule"}]}]},{"description":"HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC ","code_information":[{"code":"079","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8283.540,"maximum":14307.070,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8283.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11258.500,"methodology":"fee 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(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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Culture, fungi, definitive identification, each organism; mold ","code_information":[{"code":"305","type":"RC"},{"code":"87107","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.840,"maximum":132.110,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":132.110,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":132.110,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10.320,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":8.840,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":10.320,"methodology":"fee schedule"}]}]},{"description":"FRACTURES OF FEMUR WITHOUT MCC ","code_information":[{"code":"141","type":"RC"},{"code":"534","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Injection, lanreotide, (cipla), 1 mg ","code_information":[{"code":"636","type":"RC"},{"code":"J1932","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":63.060,"maximum":63.060,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":63.060,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":63.060,"methodology":"fee schedule"}]}]},{"description":"Brain imaging, minimum 4 static views; with vascular flow ","code_information":[{"code":"350","type":"RC"},{"code":"78606","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":332.630,"maximum":332.630,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":332.630,"methodology":"fee schedule"}]}]},{"description":"Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope or telescope ","code_information":[{"code":"31571","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1139.830,"maximum":13940.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4992.750,"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":6813.630,"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":6813.630,"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":7283.540,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1139.830,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"Implnt/abut suprtd fixd dent ","code_information":[{"code":"360","type":"RC"},{"code":"D6079","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":12814.000,"maximum":12814.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transcranial Doppler study of the intracranial arteries; vasoreactivity study ","code_information":[{"code":"922","type":"RC"},{"code":"93890","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":"Bypass graft, with vein; brachial-brachial ","code_information":[{"code":"35525","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1017.000,"maximum":15426.680,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":9370.460,"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":13793.410,"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":13793.410,"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":14616.000,"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":15426.680,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic subunit alpha) (eg, breast cancer) gene analysis ","code_information":[{"code":"0155U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":274.830,"maximum":274.830,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":274.830,"methodology":"fee 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","code_information":[{"code":"892","type":"RC"},{"code":"C9067","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5.960,"maximum":5.960,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.960,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":5.960,"methodology":"fee schedule"}]}]},{"description":"Virtual reality (VR) procedural dissociation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural ","code_information":[{"code":"0771T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":12814.000,"maximum":12814.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Duplex scan of arterial inflow and venous outflow of penile vessels; follow-up or limited study ","code_information":[{"code":"343","type":"RC"},{"code":"93981","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":72.930,"maximum":72.930,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":72.930,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only ","code_information":[{"code":"43772","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":26002.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5098.440,"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":6957.870,"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":6957.870,"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":7437.720,"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":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":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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further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 with direct optical (ie, visual) observation; Influenza ","code_information":[{"code":"87804","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":14.180,"maximum":16.550,"payers_information":[{"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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":16.550,"methodology":"fee schedule"}]}]},{"description":"Excision or destruction, open, intra-abdominal tumors, cysts or 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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":"Radiologic examination, ankle; complete, minimum of 3 views ","code_information":[{"code":"343","type":"RC"},{"code":"73610","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":37.830,"maximum":223.580,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":223.580,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":223.580,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":37.830,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of supracondylar or transcondylar 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3361.370,"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":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 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logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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; popliteal-tibial, -peroneal artery or other distal vessels ","code_information":[{"code":"35571","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3145.000,"maximum":6769.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":6769.000,"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":5198.000,"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":5198.000,"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":5055.000,"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":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transcranial Doppler study of the intracranial arteries; limited study ","code_information":[{"code":"921","type":"RC"},{"code":"93888","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":"Donor hysterectomy (including cold preservation); recipient uterus allograft transplantation from cadaver or living donor ","code_information":[{"code":"0667T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1017.000,"maximum":13988.660,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8496.970,"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":12507.630,"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":12507.630,"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":13253.550,"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":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":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"ELECTIVE KNEE JOINT REPLACEMENT ","code_information":[{"code":"3264","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":16532.130,"maximum":19183.950,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":19183.950,"methodology":"fee schedule"},{"payer_name":"Driscoll Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":17200.090,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":17534.080,"methodology":"fee 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portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":496.920,"maximum":1068.980,"gross_charge":638.95,"discounted_cash":638.95,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":1068.980,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":821.740,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":821.740,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":798.300,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":965.560,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":496.920,"methodology":"fee 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous nephrolithotomy or pyelolithotomy, lithotripsy, stone extraction, antegrade ureteroscopy, 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dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":20008.470,"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":21218.660,"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":10342.000,"methodology":"case rate"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":"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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further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple ","code_information":[{"code":"369","type":"RC"},{"code":"55876","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":76.050,"maximum":12814.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":89.470,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":401.940,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presenc ","code_information":[{"code":"361","type":"RC"},{"code":"99152","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12814.000,"maximum":12814.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Esophagogastrostomy (cardioplasty), with or without vagotomy and pyloroplasty, transabdominal or transthoracic approach ","code_information":[{"code":"367","type":"RC"},{"code":"43320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC ","code_information":[{"code":"141","type":"RC"},{"code":"673","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative ","code_information":[{"code":"343","type":"RC"},{"code":"78472","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":228.340,"maximum":1868.360,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1868.360,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1868.360,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":228.340,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, shoulder, surgical; biceps tenodesis ","code_information":[{"code":"29828","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2573.700,"maximum":26535.000,"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":10169.310,"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":13878.120,"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":13878.120,"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":14835.240,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":26535.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2573.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":14093.000,"methodology":"case rate"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"119","type":"RC"},{"code":"833","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Repair blood vessel, direct; intrathoracic, with bypass ","code_information":[{"code":"35211","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3145.000,"maximum":6769.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":6769.000,"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":5198.000,"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":5198.000,"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":5055.000,"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":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"IGH@ (Immunoglobulin heavy chain locus) (eg, leukemia and lymphoma, B-cell), variable region somatic mutation analysis ","code_information":[{"code":"303","type":"RC"},{"code":"81263","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":252.350,"maximum":3770.530,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":3770.530,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":3770.530,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":294.520,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":252.350,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":294.520,"methodology":"fee schedule"}]}]},{"description":"CONCUSSION WITH MCC ","code_information":[{"code":"088","type":"MS-DRG"},{"code":"150","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":13878.120,"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":14835.240,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2573.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"INSERTION OF INFUSION PUMP 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","code_information":[{"code":"401","type":"RC"},{"code":"78120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":71.910,"maximum":681.210,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":681.210,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":681.210,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":71.910,"methodology":"fee schedule"}]}]},{"description":"Renal exploration, not necessitating other specific procedures ","code_information":[{"code":"480","type":"RC"},{"code":"50010","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 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adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6922.900,"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":6922.900,"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":7400.340,"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":7847.950,"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":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); without ossicular chain reconstruction High Cost Surgery","code_information":[{"code":"360","type":"RC"},{"code":"69635","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2369.000,"maximum":2369.000,"payers_information":[{"payer_name":"Superior 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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 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procedure logic."}]}]},{"description":"Aspiration of bladder; with insertion of suprapubic catheter ","code_information":[{"code":"481","type":"RC"},{"code":"51102","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":700.490,"maximum":13940.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3011.630,"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":4110.000,"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":4110.000,"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":4393.440,"methodology":"fee schedule","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 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further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, thiotepa (tepylute), 1 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J9341","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":63.610,"maximum":63.610,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":63.610,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":63.610,"methodology":"fee schedule"}]}]},{"description":"Removal of tunneled intraperitoneal catheter ","code_information":[{"code":"104552","type":"CDM"},{"code":"49422","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1107.040,"maximum":3384.000,"gross_charge":19128.06,"discounted_cash":19128.06,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3384.000,"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":2600.000,"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":2600.000,"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":2528.000,"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":3057.000,"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":1573.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":1151.770,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1230.040,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1230.040,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1230.040,"methodology":"fee 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":2531.050,"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":2531.050,"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":2682.000,"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":2830.750,"methodology":"fee schedule","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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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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logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Adenoidectomy, secondary; age 12 or over ","code_information":[{"code":"367","type":"RC"},{"code":"42836","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6315.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Leukocyte transfusion ","code_information":[{"code":"319","type":"RC"},{"code":"86950","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":780.860,"maximum":780.860,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":780.860,"methodology":"fee 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logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":"Legg perthes orthosis, (newington type), custom fabricated ","code_information":[{"code":"L1710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2527.080,"maximum":29445.600,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":2556.220,"methodology":"fee schedule"},{"payer_name":"American Health 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schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":5018.670,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":2534.680,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":29445.600,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":2534.680,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":2534.680,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":2534.680,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":2534.680,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":29445.600,"methodology":"fee schedule"},{"payer_name":"Independent Medical 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of Texas","plan_name":"POS","standard_charge_dollar":2686.760,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":2686.760,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":2686.760,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":2661.410,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":3928.750,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":2661.410,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":2661.410,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":2661.410,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare 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"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9465.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $658089.00, reimbursement will be $9450 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":3876.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $658089.00, reimbursement will be $5250 per diem instead of the contracted rate."}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS ","code_information":[{"code":"065","type":"MS-DRG"},{"code":"152","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":136.420,"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":144.680,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3764.760,"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":4024.400,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":760.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"Insertion of drug-eluting implant, including punctal dilation when performed, into lacrimal canaliculus, each ","code_information":[{"code":"490","type":"RC"},{"code":"68841","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":553.590,"maximum":13940.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":553.590,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":755.480,"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":755.480,"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":807.590,"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":856.430,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"Albumin; serum, plasma or whole blood ","code_information":[{"code":"319","type":"RC"},{"code":"82040","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.240,"maximum":63.360,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":63.360,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":63.360,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":4.240,"methodology":"fee schedule"}]}]},{"description":"Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; init ","code_information":[{"code":"37238","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":42613.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":16844.420,"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":22987.670,"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":22987.670,"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":24573.030,"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":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":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":42613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":5488.280,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":22987.000,"methodology":"case rate"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuve High Cost Surgery","code_information":[{"code":"37274","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":"Ankle disarticulation ","code_information":[{"code":"27889","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2573.700,"maximum":15732.530,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10169.310,"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":13878.120,"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":13878.120,"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":14835.240,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2573.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"Level 5 hospital emergency department visit provided in a type b 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3404.050,"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":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":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 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","code_information":[{"code":"360","type":"RC"},{"code":"50236","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":19777.750,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":12013.380,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":17683.820,"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":17683.820,"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":18738.430,"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":19777.750,"methodology":"fee schedule","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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Percutaneous skeletal fixation of talotarsal joint dislocation, with manipulation ","code_information":[{"code":"28576","type":"CPT"},{"code":"361","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":10169.310,"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":13878.120,"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":13878.120,"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":14835.240,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2573.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"Non-randomized, non-blinded procedure for nyha class ii, iii, iv heart failure; transcatheter implantation of interatrial shunt, including right and left heart catheterization, transeptal puncture, tr 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Zero instances of this service in the last 15 months prior to posting. 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3144.500,"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":3144.500,"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":3361.370,"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":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 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logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"EGFR (epidermal growth factor receptor) (eg, non-small cell lung cancer) gene analysis, common variants (eg, exon 19 LREA deletion, L858R, T790M, G719A, G719S, L861Q) ","code_information":[{"code":"304","type":"RC"},{"code":"81235","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":278.100,"maximum":3365.890,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":3365.890,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":3365.890,"methodology":"fee 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be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1007.060,"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":1063.080,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12507.630,"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":13253.550,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Thromboendarterectomy, including patch graft, if performed; deep (profunda) femoral 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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":"PPO","standard_charge_dollar":13230.240,"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 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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":"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s) ","code_information":[{"code":"71550","type":"CPT"},{"code":"924","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":"Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, include 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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":"PPO","standard_charge_dollar":41922.120,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure 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logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Chemodenervation of one extremity; each additional extremity, 5 or more muscles (List separately in addition to code for primary procedure) 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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":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Hemoglobin, quantitative, transcutaneous, per day; carboxyhemoglobin 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","code_information":[{"code":"344","type":"RC"},{"code":"Q4412","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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"HEndovascular repair of infrarenal abdominal aortic aneurysm or dissection; using modular bifurcated prosthesis (1 docking limb) ","code_information":[{"code":"34802","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":12814.000,"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 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rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, thoracic ","code_information":[{"code":"63281","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":28554.310,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":17344.430,"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":25531.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":25531.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":27053.770,"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":28554.310,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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 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(in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6429.370,"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":6872.770,"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":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":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"Cineradiography/videoradiography to complement routine examination (List separately in addition to code for primary procedure) ","code_information":[{"code":"349","type":"RC"},{"code":"76125","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":357.970,"maximum":357.970,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":357.970,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":357.970,"methodology":"fee schedule"}]}]},{"description":"OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC 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logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":5198.000,"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":5198.000,"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":5055.000,"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":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":12507.630,"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":12507.630,"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":13253.550,"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":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":12814.000,"methodology":"case 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","code_information":[{"code":"27030","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3041.000,"maximum":20821.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":7653.910,"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":11266.630,"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":11266.630,"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":11938.540,"methodology":"fee 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"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3873.000,"methodology":"case rate","additional_payer_notes":"Days 5+. "},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3873.000,"methodology":"case rate","additional_payer_notes":"Days 5+. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3768.000,"methodology":"case rate","additional_payer_notes":"Days 5+. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4558.000,"methodology":"case rate","additional_payer_notes":"Days 5+. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2344.000,"methodology":"case rate","additional_payer_notes":"Days 5+. "}]}]},{"description":"Open closure of major bronchial fistula ","code_information":[{"code":"32815","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; submental ","code_information":[{"code":"361","type":"RC"},{"code":"41016","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":13940.000,"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":8245.900,"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":11253.230,"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":11253.230,"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":12029.310,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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","code_information":[{"code":"A0384","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":551.330,"maximum":551.330,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":551.330,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":551.330,"methodology":"fee schedule"}]}]},{"description":"Sweat collection by iontophoresis ","code_information":[{"code":"300","type":"RC"},{"code":"89230","type":"CPT"},{"code":"893601","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":34.530,"maximum":49.760,"gross_charge":992.41,"discounted_cash":992.41,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":34.530,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":34.530,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":49.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":49.760,"methodology":"fee schedule"}]}]},{"description":"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WIT Adult","code_information":[{"code":"562","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":20514.000,"maximum":27429.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":20514.000,"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":23245.000,"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":27429.000,"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":"REPAIR OF TENNIS ELBOW ","code_information":[{"code":"24350","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":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"Lateral retinacular release, open High Cost Surgery","code_information":[{"code":"27425","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":"Instillation of fecal microbiota suspension via rectal enema into lower gastrointestinal tract ","code_information":[{"code":"0780T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1022.000,"maximum":13988.660,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8496.970,"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":12507.630,"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":12507.630,"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":13253.550,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"REMOVAL OF ACCESS DEVICE ","code_information":[{"code":"36535","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":"HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC ","code_information":[{"code":"001","type":"MS-DRG"},{"code":"167","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"INSERTION OF CATHETER, VEIN ","code_information":[{"code":"36491","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":"Repair blood vessel with graft other than vein; neck ","code_information":[{"code":"35261","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers 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logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":5198.000,"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":5198.000,"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":5055.000,"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":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens 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 MCO","plan_name":"CHIP","standard_charge_dollar":1088.270,"methodology":"fee schedule"}]}]},{"description":"Puncture aspiration of cyst of breast; each additional cyst (List separately in 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elsewhere specified ","code_information":[{"code":"305","type":"RC"},{"code":"86671","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.500,"maximum":156.900,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":156.900,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":156.900,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.250,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":10.500,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":12.250,"methodology":"fee schedule"}]}]},{"description":"Sequestrectomy (eg, for osteomyelitis or bone abscess), humeral head to surgical neck ","code_information":[{"code":"23174","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1818.000,"maximum":3915.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3915.000,"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":3005.000,"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":3005.000,"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":2923.000,"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":3537.000,"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":1818.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens 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 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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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (cutaneous melanoma), RNA, gene expression profiling by realtime qPCR of 10 genes (8 content and 2 housekeeping), utilizing formalin-fixed ","code_information":[{"code":"0578U","type":"CPT"},{"code":"309","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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":3873.000,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy, with insertion of temporary prostatic implant/stent with fixation/anchor and incisional struts ","code_information":[{"code":"750","type":"RC"},{"code":"C9769","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4807.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance spectroscopy ","code_information":[{"code":"322","type":"RC"},{"code":"76390","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3756.740,"maximum":3756.740,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":3756.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":3756.740,"methodology":"fee schedule"}]}]},{"description":"Closure of single ventricular septal defect, with or without patch; with removal of pulmonary artery band, with or without gusset ","code_information":[{"code":"33688","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":25555.720,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":15523.030,"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":22850.060,"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":22850.060,"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":24212.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25555.720,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC ","code_information":[{"code":"142","type":"RC"},{"code":"965","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; system, including 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"REMOVE LUNG & REVISE CHEST ","code_information":[{"code":"32522","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":"Management of liver hemorrhage; complex suture of liver wound or injury, with or without hepatic artery ligation ","code_information":[{"code":"47360","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1017.000,"maximum":25406.530,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":15432.400,"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":22716.650,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":22716.650,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":24071.410,"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":25406.530,"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":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":5841.000,"methodology":"case 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procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":127.620,"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":136.420,"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":144.680,"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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procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":8286.000,"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":8060.000,"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":9748.000,"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":5013.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Amnioamp-mp, per square centimeter (add-on, list separately in addition to primary procedure) 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":4024.400,"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":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":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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further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and rescreening under physician supervision ","code_information":[{"code":"88165","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.110,"maximum":446.910,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":446.910,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":343.540,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":42.580,"methodology":"fee 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","code_information":[{"code":"0274U","type":"CPT"},{"code":"305","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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":608.170,"methodology":"fee schedule"}]}]},{"description":"Trabeculotomy by laser, including optical coherence tomography (OCT) guidance ","code_information":[{"code":"0730T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1017.000,"maximum":13988.660,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8496.970,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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","code_information":[{"code":"311","type":"RC"},{"code":"82600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.630,"maximum":248.360,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":248.360,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":248.360,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":16.630,"methodology":"fee schedule"}]}]},{"description":"Pregnenolone ","code_information":[{"code":"300","type":"RC"},{"code":"84140","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.710,"maximum":264.640,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":264.640,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":264.640,"methodology":"fee 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adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":5771.000,"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":5612.000,"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":6788.000,"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":3491.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Semen analysis; presence and/or motility of sperm including Huhner test (post coital) ","code_information":[{"code":"89300","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":9.840,"maximum":9.840,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9.840,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9.840,"methodology":"fee schedule"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance ","code_information":[{"code":"43236","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":331.600,"maximum":3915.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3915.000,"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":3005.000,"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":3005.000,"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":2923.000,"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":3537.000,"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":1818.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":345.000,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":368.440,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":368.440,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":368.440,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":368.440,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":331.600,"methodology":"fee schedule"},{"payer_name":"USA MCO","plan_name":"CHIP","standard_charge_dollar":334.950,"methodology":"fee schedule"}]}]},{"description":"Salivary gland imaging; with serial images ","code_information":[{"code":"78231","type":"CPT"},{"code":"921","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":106.340,"maximum":106.340,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":106.340,"methodology":"fee schedule"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) ","code_information":[{"code":"43235","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":359.420,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1336.060,"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":1823.330,"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":1823.330,"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":1949.080,"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":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":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":359.420,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/ ","code_information":[{"code":"512","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.000,"maximum":40072.270,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":15251.140,"methodology":"fee schedule"},{"payer_name":"Affiliated Healthcare","plan_name":"COMM","standard_charge_percentage":68.00,"standard_charge_algorithm":"Reimbursement will be 68% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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_dollar":16224.620,"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":19889.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":24425.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":24425.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":27957.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":15452.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":15452.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":15452.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":31487.950,"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":84.00,"standard_charge_algorithm":"Reimbursement will be 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":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":15297.500,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":15297.500,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":15297.500,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":15297.500,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":15297.500,"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":21875.420,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":22592.900,"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":"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":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":"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":14756.680,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":40072.270,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":14756.680,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":14756.680,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":14756.680,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":14756.680,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":40072.270,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":23068.000,"methodology":"fee schedule"},{"payer_name":"MCM Maxcare","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":"Molina","plan_name":"MGMCR","standard_charge_dollar":16842.700,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":22291.620,"methodology":"fee schedule"},{"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":23201.210,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":20609.730,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":15915.580,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":16224.620,"methodology":"fee schedule"},{"payer_name":"ProNet PPO","plan_name":"PPO","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":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":15761.060,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":15761.060,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":15761.060,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":15761.060,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":15761.060,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":16533.660,"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":23950.630,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":16224.620,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":16224.620,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":16224.620,"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":15452.020,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":16224.620,"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":"Total E&P Mexico","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":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":15452.020,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17829.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"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":15282.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":28.70,"standard_charge_algorithm":"Reimbursement will be 28.7% 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":"United","plan_name":"SmallGroup","standard_charge_dollar":9617.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"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":15761.060,"methodology":"fee schedule"}]}]},{"description":"Targeted genomic sequence analysis panel, solid organ neoplasm, circulating cell-free DNA (cfDNA) analysis from plasma of 521 genes, interrogation for sequence variants, ","code_information":[{"code":"0585U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2919.600,"maximum":2919.600,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2919.600,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":2919.600,"methodology":"fee schedule"}]}]},{"description":"Antidepressants, not otherwise specified ","code_information":[{"code":"302","type":"RC"},{"code":"80338","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.920,"maximum":122.570,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":122.570,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":122.570,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":10.920,"methodology":"fee schedule"}]}]},{"description":"Percutaneous breast biopsies using stereotactic guidance, with placement of breast localization device(s) (e.g., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when perfor ","code_information":[{"code":"750","type":"RC"},{"code":"C7501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1017.000,"maximum":13988.660,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8496.970,"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":12507.630,"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":12507.630,"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":13253.550,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Amnio wound, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"636","type":"RC"},{"code":"Q4181","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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC ","code_information":[{"code":"10D07Z8","type":"ICD"},{"code":"132","type":"RC"},{"code":"798","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2344.000,"maximum":5046.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5046.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3873.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3873.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3768.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4558.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2344.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "}]}]},{"description":"Galactose-1-phosphate uridyl transferase; screen ","code_information":[{"code":"304","type":"RC"},{"code":"82776","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.060,"maximum":121.740,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":121.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":121.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":10.060,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":11.740,"methodology":"fee schedule"}]}]},{"description":"Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with right and left heart ","code_information":[{"code":"750","type":"RC"},{"code":"C7527","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1017.000,"maximum":12018.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4637.660,"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":5816.000,"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":5816.000,"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":7253.780,"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":8680.750,"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":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Elevation of depressed skull fracture; simple, extradural ","code_information":[{"code":"369","type":"RC"},{"code":"62000","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4452.790,"maximum":20821.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4452.790,"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":6076.750,"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":6076.750,"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":6495.840,"methodology":"fee schedule","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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":20821.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":11042.000,"methodology":"case rate"}]}]},{"description":"Closure of enterostomy, large or small intestine; ","code_information":[{"code":"367","type":"RC"},{"code":"44620","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tenodesis of long tendon of biceps ","code_information":[{"code":"23430","type":"CPT"},{"code":"480","type":"RC"}],"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":"Excision, ischial pressure ulcer, with skin flap closure; with ostectomy ","code_information":[{"code":"15945","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6315.000,"maximum":12814.000,"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 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","code_information":[{"code":"480","type":"RC"},{"code":"65275","type":"CPT"}],"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":"Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; each additional fractured vertebra or dislocated segment ","code_information":[{"code":"22328","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1022.000,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2336.940,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further 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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 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rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Repair of single ventricle with aortic outflow obstruction and aortic arch hypoplasia (hypoplastic left heart syndrome) (eg, Norwood procedure) ","code_information":[{"code":"33619","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1017.000,"maximum":37013.830,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":22482.900,"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":33095.060,"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":33095.060,"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":35068.750,"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":37013.830,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"CORRECTION OF BUNION ","code_information":[{"code":"28293","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4988.000,"maximum":8328.000,"payers_information":[{"payer_name":"Healthcare 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multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":13397.370,"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":13397.370,"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":14196.340,"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":14983.740,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) ","code_information":[{"code":"300","type":"RC"},{"code":"85027","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.540,"maximum":82.750,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":82.750,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":82.750,"methodology":"fee schedule"},{"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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":6.470,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC ","code_information":[{"code":"121","type":"RC"},{"code":"754","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC ","code_information":[{"code":"130","type":"RC"},{"code":"308","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Valproic acid (dipropylacetic acid); total ","code_information":[{"code":"304","type":"RC"},{"code":"80164","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.600,"maximum":173.390,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":173.390,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":173.390,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.540,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":11.600,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":13.540,"methodology":"fee schedule"}]}]},{"description":"Repair, nonunion or malunion, femur, distal to head and neck; with iliac or other autogenous bone graft (includes obtaining graft) ","code_information":[{"code":"27472","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3491.000,"maximum":7514.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":7514.000,"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":5771.000,"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":5771.000,"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":5612.000,"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":6788.000,"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":3491.000,"methodology":"case rate","additional_payer_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":"409","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":"Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 3.1 to 4.0 cm ","code_information":[{"code":"11644","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":521.990,"maximum":12814.000,"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":2333.420,"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":3184.430,"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":3184.430,"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":3404.050,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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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less than 5 cm ","code_information":[{"code":"22904","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":874.740,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3942.110,"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":5379.820,"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":5379.820,"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":5750.850,"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":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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":874.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC ","code_information":[{"code":"112","type":"RC"},{"code":"939","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Urobilinogen, urine; qualitative 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logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":5055.000,"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":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens 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 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":16710.380,"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":17637.220,"methodology":"fee schedule","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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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 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procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":474.240,"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":500.620,"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":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 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":15618.990,"methodology":"fee schedule","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 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rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants ","code_information":[{"code":"312","type":"RC"},{"code":"81212","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":376.990,"maximum":4562.800,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":4562.800,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":4562.800,"methodology":"fee 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11253.230,"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":12029.310,"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":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 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3361.370,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":636.360,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC 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logic."}]}]},{"description":"Rhytidectomy; glabellar frown lines ","code_information":[{"code":"15826","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1564.090,"maximum":15613.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5061.390,"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":6907.310,"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":6907.310,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":25829.980,"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":27262.640,"methodology":"fee schedule","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":"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 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8179.760,"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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rate","additional_payer_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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"Antihuman globulin test (Coombs test); indirect, qualitative, each reagent red cell ","code_information":[{"code":"305","type":"RC"},{"code":"86885","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.900,"maximum":73.320,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":73.320,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":73.320,"methodology":"fee 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"APPENDIX PROCEDURES WITH MCC ","code_information":[{"code":"101","type":"RC"},{"code":"397","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Bone graft, any donor area; major or large ","code_information":[{"code":"20902","type":"CPT"},{"code":"369","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":10169.310,"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":13878.120,"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":13878.120,"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":14835.240,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2573.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"Unlisted fluoroscopic procedure (eg, diagnostic, interventional) 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","code_information":[{"code":"361","type":"RC"},{"code":"D4230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":12814.000,"maximum":12814.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INTRAOCULAR PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"117","type":"MS-DRG"},{"code":"121","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per 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logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"Donor egg cycle, incomplete, case rate ","code_information":[{"code":"481","type":"RC"},{"code":"S4023","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":12814.000,"maximum":12814.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 ","code_information":[{"code":"140","type":"RC"},{"code":"354","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Avulsion of nail plate, partial or complete, simple; each additional nail plate (List separately in addition to code for primary procedure) 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","code_information":[{"code":"26025","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":12814.000,"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":4653.660,"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":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6788.880,"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":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 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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES ","code_information":[{"code":"2292","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7154.240,"maximum":8301.820,"payers_information":[{"payer_name":"Aetna Better 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Health","plan_name":"MGMCD","standard_charge_dollar":3027.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10169.310,"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":13878.120,"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":13878.120,"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":14835.240,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":20821.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2573.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":11042.000,"methodology":"case rate"}]}]},{"description":"Exchange of previously placed abscess or cyst drainage catheter under radiological guidance (separate procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"49423","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":606.240,"maximum":12814.000,"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":2647.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3613.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3613.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3862.350,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":606.240,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC ","code_information":[{"code":"111","type":"RC"},{"code":"314","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC ","code_information":[{"code":"150","type":"RC"},{"code":"326","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Mastoid obliteration (separate procedure) High Cost Surgery","code_information":[{"code":"361","type":"RC"},{"code":"69670","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":"RADIOTHERAPY Adult","code_information":[{"code":"849","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17133.000,"maximum":22908.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":17133.000,"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":19413.000,"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":22908.000,"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":"ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS, WITH IMAGE GUIDANCE, INCLUDES PLACEMENT OF INTRA-ARTICULAR IMPLANT(S) (EG, BONE ALLOGRAFTºS», SYNTHETIC DEVICEºS») ","code_information":[{"code":"0775T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":9875.000,"maximum":9875.000,"payers_information":[{"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."}]}]},{"description":"Exenteration of orbit (does not include skin graft), removal of orbital contents; with therapeutic removal of bone ","code_information":[{"code":"65112","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1092.390,"maximum":10792.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":10792.000,"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":8286.000,"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":8286.000,"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":8060.000,"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":9748.000,"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":5013.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":1136.520,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1213.760,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1213.760,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1213.760,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1213.760,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":1092.390,"methodology":"fee schedule"},{"payer_name":"USA MCO","plan_name":"CHIP","standard_charge_dollar":1103.420,"methodology":"fee schedule"}]}]},{"description":"ATHEROSCLEROSIS WITH MCC ","code_information":[{"code":"131","type":"RC"},{"code":"302","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"REPAIR OF DIAPHRAGM HERNIA ","code_information":[{"code":"39520","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":3675.000,"payers_information":[{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"HAND TENDON RECONSTRUCTION ","code_information":[{"code":"26504","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":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6788.880,"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":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":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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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logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":5198.000,"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":5198.000,"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":5055.000,"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":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, metoclopramide hcl, up to 10 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J2765","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1.780,"maximum":1.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1.780,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1.780,"methodology":"fee schedule"}]}]},{"description":"Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) without removal of antrochoanal polyps 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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":"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":20821.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2096.960,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":11042.000,"methodology":"case rate"}]}]},{"description":"Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or ","code_information":[{"code":"480","type":"RC"},{"code":"50553","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3041.000,"maximum":3041.000,"payers_information":[{"payer_name":"Healthcare 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":778.790,"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":825.800,"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":871.730,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":95.950,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"Breath hydrogen or methane test (eg, for detection of lactase deficiency, 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","code_information":[{"code":"33840","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":16760.530,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10180.670,"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":14986.040,"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":14986.040,"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":15879.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16760.530,"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 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3699.090,"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":3922.360,"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":4140.550,"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 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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":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":460.610,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"Endovascular stent repair of coarctation of the ascending, transverse, or descending thoracic or abdominal aorta, involving stent placement; across major side branches 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further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":13878.120,"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":13878.120,"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":14835.240,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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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rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Fibrinogen; activity ","code_information":[{"code":"85384","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8.320,"maximum":9.720,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9.720,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":8.320,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9.720,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, vibration) elastography 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logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2600.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":98.390,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":2600.000,"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":2528.000,"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":3057.000,"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":1573.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":102.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":76.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":127.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":127.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":135.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":97.560,"methodology":"fee 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1979.960,"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":2090.100,"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":2012.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":4352.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":223.540,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":2310.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, sinuses, paranasal, less than 3 views 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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":"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 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rate","additional_payer_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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":237.960,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"MAJOR CHEST PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"152","type":"RC"},{"code":"165","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per 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adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":11908.770,"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":11908.770,"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":12618.970,"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":13318.880,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Antibody; Helicobacter pylori 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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":"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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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schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6788.880,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":19723.770,"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":20817.740,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Ablation of prostate tissue, transurethral, using thermal 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"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3873.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3873.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3768.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4558.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2344.000,"methodology":"case rate","additional_payer_notes":"Days 3+. 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1283.980,"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 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logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":20821.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2096.960,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":11042.000,"methodology":"case rate"}]}]},{"description":"Electrolyte panel This panel must include the following: Carbon 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adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Percutaneous vertebroplasties (bone biopsies included when performed), first lumbosacral and any additional cervicothoracic or lumbosacral vertebral bodies, unilateral or bilateral injection, inclusiv 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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":"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Clotting inhibitors or anticoagulants; protein C, activity ","code_information":[{"code":"314","type":"RC"},{"code":"85303","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.860,"maximum":177.120,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":177.120,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":177.120,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":11.860,"methodology":"fee schedule"}]}]},{"description":"Open implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":13878.120,"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":14835.240,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":26535.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2573.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":14093.000,"methodology":"case rate"}]}]},{"description":"Cast supplies, long arm cast, pediatric (0-10 years), fiberglass 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adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3144.500,"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":3361.370,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; over 30.0 cm ","code_information":[{"code":"12047","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC ","code_information":[{"code":"164","type":"RC"},{"code":"821","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC ","code_information":[{"code":"117","type":"RC"},{"code":"155","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Injection, procainamide hcl, up to 1 gm ","code_information":[{"code":"636","type":"RC"},{"code":"J2690","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":568.470,"maximum":568.470,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":568.470,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":568.470,"methodology":"fee schedule"}]}]},{"description":"Esophagogastric fundoplasty, with fundic patch (Thal-Nissen procedure) ","code_information":[{"code":"367","type":"RC"},{"code":"43325","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MEDICAL BACK PROBLEMS WITHOUT MCC ","code_information":[{"code":"143","type":"RC"},{"code":"552","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Insertion or replacement of implantable cardioverter-defibrillator system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (includes defibrillation thre ","code_information":[{"code":"0571T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":12814.000,"maximum":84903.340,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":54880.490,"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":74895.720,"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":74895.720,"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":80060.950,"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":84903.340,"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_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":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":29535.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":15931.000,"methodology":"case rate"}]}]},{"description":"Immediate post-surgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, partial hand including fingers ","code_information":[{"code":"L6037","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1088.250,"maximum":1791.870,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1088.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1604.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1604.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1698.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1791.870,"methodology":"fee schedule"}]}]},{"description":"TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; targeted sequence analysis (eg, 4 oncology) ","code_information":[{"code":"101496","type":"CDM"},{"code":"81352","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":274.020,"maximum":862.970,"gross_charge":1022.00,"discounted_cash":1022.00,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":332.310,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":298.930,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":345.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":524.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":772.270,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":772.270,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":818.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":329.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":329.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":329.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":862.970,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":329.510,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":329.510,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":329.510,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":329.510,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":329.510,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":652.430,"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 Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":285.090,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":329.510,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":329.510,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":329.510,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":329.510,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":329.510,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":329.510,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":359.170,"methodology":"fee 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Health","plan_name":"MCRHMO","standard_charge_dollar":345.990,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":349.280,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":349.280,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":349.280,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":349.280,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":349.280,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":345.990,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":510.740,"methodology":"fee 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rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tenotomy, flexor, palm, open, each tendon ","code_information":[{"code":"26450","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":12814.000,"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":4653.660,"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":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6788.880,"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":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 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"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3873.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3873.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3768.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4558.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2344.000,"methodology":"case rate","additional_payer_notes":"Days 3+. 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logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC ","code_information":[{"code":"164","type":"RC"},{"code":"498","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per 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rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy ","code_information":[{"code":"314","type":"RC"},{"code":"81507","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":681.160,"maximum":8244.150,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":8244.150,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":8244.150,"methodology":"fee 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","code_information":[{"code":"35556","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiopharmaceutical quantification measurement(s) single area (List separately in addition to code for primary procedure) ","code_information":[{"code":"78835","type":"CPT"},{"code":"921","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":94.400,"maximum":94.400,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":94.400,"methodology":"fee schedule"}]}]},{"description":"Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with other flap 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logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, ankle, arthrography, radiological supervision and interpretation ","code_information":[{"code":"344","type":"RC"},{"code":"73615","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":132.920,"maximum":769.870,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":769.870,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":769.870,"methodology":"fee 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(in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"033","type":"MS-DRG"},{"code":"164","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 WITH CC ","code_information":[{"code":"133","type":"RC"},{"code":"908","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Backbench standard preparation of cadaver or living donor uterine allograft prior to transplantation, including dissection and 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13253.550,"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":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":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Unlisted procedure, rectum ","code_information":[{"code":"45999","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1298.600,"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":1772.200,"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":1772.200,"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":1894.420,"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":2009.000,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":4352.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":2310.000,"methodology":"case rate"}]}]},{"description":"Odontics endosteal implant ","code_information":[{"code":"490","type":"RC"},{"code":"D6010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":12814.000,"maximum":12814.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Histotripsy (i.e., non-thermal ablation via acoustic energy delivery) of malignant renal tissue, including image guidance ","code_information":[{"code":"362","type":"RC"},{"code":"C9790","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":12814.000,"maximum":12814.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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) ","code_information":[{"code":"480","type":"RC"},{"code":"67041","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6326.000,"maximum":6326.000,"payers_information":[{"payer_name":"Healthcare 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(in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":723.530,"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":767.200,"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":809.880,"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 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for lateral trunk or hip support, any type ","code_information":[{"code":"E1034","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":28.840,"maximum":47.480,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":28.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":42.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":42.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":45.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":47.480,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, spine, cervical; 4 or 5 views ","code_information":[{"code":"324","type":"RC"},{"code":"72050","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":54.530,"maximum":290.050,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":290.050,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":290.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":245.180,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":54.530,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":245.180,"methodology":"fee schedule"}]}]},{"description":"CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC ","code_information":[{"code":"847","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1275.000,"maximum":9465.000,"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":9465.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $658089.00, reimbursement will be $9450 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":3876.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  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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":12814.000,"methodology":"case 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further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tracheostomy, emergency procedure; transtracheal ","code_information":[{"code":"31603","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":451.360,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2293.880,"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":3130.470,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"F5 (coagulation factor V) (eg, hereditary hypercoagulability) gene analysis, Leiden variant ","code_information":[{"code":"314","type":"RC"},{"code":"81241","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":62.860,"maximum":782.310,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":782.310,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":782.310,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":62.860,"methodology":"fee schedule"}]}]},{"description":"Repair medial collateral ligament, elbow, with local tissue ","code_information":[{"code":"24345","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2573.700,"maximum":15732.530,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10169.310,"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":13878.120,"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":13878.120,"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":14835.240,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2573.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"Excision of lesion, conjunctiva; over 1 cm ","code_information":[{"code":"362","type":"RC"},{"code":"68115","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4104.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia ","code_information":[{"code":"52260","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":700.490,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3011.630,"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":4110.000,"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":4110.000,"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":4393.440,"methodology":"fee schedule","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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":700.490,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"Computed tomography guidance for, and monitoring of, parenchymal tissue ablation ","code_information":[{"code":"322","type":"RC"},{"code":"77013","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4305.110,"maximum":4305.110,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":4305.110,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":4305.110,"methodology":"fee schedule"}]}]},{"description":"Dermabrasion; segmental, face ","code_information":[{"code":"15781","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3145.000,"maximum":6769.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":6769.000,"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":5198.000,"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":5198.000,"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":5055.000,"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":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Distal revascularization and interval ligation (DRIL), upper extremity hemodialysis access (steal syndrome) ","code_information":[{"code":"36838","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":7813.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":10663.160,"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":10663.160,"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":11398.550,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":11962.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":6598.000,"methodology":"case rate"}]}]},{"description":"Dynamic knee, extension/flexion device with active 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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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Esophagoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) over guide wire 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logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":3057.000,"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":1573.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens 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 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for multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"}]}]},{"description":"Excision of coarctation of aorta, with or without associated patent ductus arteriosus; with direct anastomosis ","code_information":[{"code":"33840","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3145.000,"maximum":6769.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":6769.000,"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":5198.000,"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":5198.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) 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","code_information":[{"code":"27590","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":23368.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":6501.010,"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":9569.550,"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":9569.550,"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":10140.250,"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":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 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s) ","code_information":[{"code":"361","type":"RC"},{"code":"43291","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1403.370,"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":1915.180,"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":1915.180,"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":2047.260,"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":2171.090,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":18096.640,"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":19175.870,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"MR safety implant electronics preparation under supervision of physician or other qualified health care professional, including MR-specific programming of pulse generator and/or transmitter to verify ","code_information":[{"code":"76018","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":198.270,"maximum":380.010,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":198.270,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":319.430,"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":3330.670,"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 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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 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logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":5198.000,"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":5198.000,"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":5055.000,"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":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; each additional gestation (List separa ","code_information":[{"code":"404","type":"RC"},{"code":"76812","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":195.970,"maximum":195.970,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":195.970,"methodology":"fee schedule"}]}]},{"description":"Removal of pulse generator for 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":7400.340,"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":7847.950,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"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":"323","type":"RC"},{"code":"70559","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2457.690,"maximum":2457.690,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":2457.690,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":2457.690,"methodology":"fee schedule"}]}]},{"description":"Injection procedure for sialography ","code_information":[{"code":"42550","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision and interpretation ","code_information":[{"code":"351","type":"RC"},{"code":"75726","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":174.840,"maximum":174.840,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":174.840,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) ","code_information":[{"code":"369","type":"RC"},{"code":"58571","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3337.160,"maximum":26535.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":3926.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":14302.290,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":19518.420,"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":19518.420,"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":20864.510,"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":22126.480,"methodology":"fee schedule","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":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":11558.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":26535.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":3337.160,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":14093.000,"methodology":"case rate"}]}]},{"description":"Graphite crucible for preparation of technetium tc 99m-labeled carbon aerosol, one crucible ","code_information":[{"code":"344","type":"RC"},{"code":"A9506","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":542.190,"maximum":542.190,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":542.190,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":542.190,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC ","code_information":[{"code":"101","type":"RC"},{"code":"10D07Z4","type":"ICD"},{"code":"798","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2344.000,"maximum":5046.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5046.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3873.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3873.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3768.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4558.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2344.000,"methodology":"case rate","additional_payer_notes":"Days 3+. "}]}]},{"description":"Growth hormone suppression panel (glucose administration) This panel must include the following: Glucose (82947 x 3) Human growth hormone (HGH) (83003 x 4) ","code_information":[{"code":"80430","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":110.810,"maximum":129.330,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":129.330,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":110.810,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":129.330,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, osseous survey; complete (axial and appendicular skeleton) ","code_information":[{"code":"77075","type":"CPT"},{"code":"929","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":102.240,"maximum":102.240,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":102.240,"methodology":"fee schedule"}]}]},{"description":"Rhytidectomy; glabellar frown lines ","code_information":[{"code":"15826","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transcranial Doppler study of the intracranial arteries; complete study ","code_information":[{"code":"349","type":"RC"},{"code":"93886","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":"Radiologic examination, small intestine, including multiple serial images and scout abdominal radiograph(s), when performed; double-contrast (eg, high-density barium and air via enteroclysis tube) stu ","code_information":[{"code":"612","type":"RC"},{"code":"74251","type":"CPT"}],"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":"EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT ","code_information":[{"code":"927","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.000,"maximum":516831.550,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":166276.240,"methodology":"fee schedule"},{"payer_name":"Affiliated Healthcare","plan_name":"COMM","standard_charge_percentage":68.00,"standard_charge_algorithm":"Reimbursement will be 68% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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_dollar":176889.610,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 24. "},{"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_percentage":19.70,"standard_charge_algorithm":"Reimbursement will be 19.7% 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":"BCBS","plan_name":"BlueEssentials","standard_charge_percentage":29.00,"standard_charge_algorithm":"Reimbursement will be 29% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"BlueEssentialsAccess","standard_charge_percentage":29.00,"standard_charge_algorithm":"Reimbursement will be 29% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":"HealthSelectOpenAccess(EPOSOA)","standard_charge_percentage":30.70,"standard_charge_algorithm":"Reimbursement will be 30.7% 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":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":168466.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":168466.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":168466.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":32.40,"standard_charge_algorithm":"Reimbursement will be 32.4% 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":"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":84.00,"standard_charge_algorithm":"Reimbursement will be 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":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_percentage":20.40,"standard_charge_algorithm":"Reimbursement will be 20.4% 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":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":23.10,"standard_charge_algorithm":"Reimbursement will be 23.1% 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":"Cigna","plan_name":"PPO","standard_charge_percentage":27.30,"standard_charge_algorithm":"Reimbursement will be 27.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":166781.640,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":166781.640,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":166781.640,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":166781.640,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":166781.640,"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":238497.740,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_percentage":46.30,"standard_charge_algorithm":"Reimbursement will be 46.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"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":"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":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":"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":160885.320,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":516831.550,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":160885.320,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":160885.320,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":160885.320,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":160885.320,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":516831.550,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","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":"MCM Maxcare","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":"Molina","plan_name":"MGMCR","standard_charge_dollar":183628.270,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":287505.830,"methodology":"fee schedule"},{"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":252952.150,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_percentage":26.20,"standard_charge_algorithm":"Reimbursement will be 26.2% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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_dollar":173520.290,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":176889.610,"methodology":"fee schedule"},{"payer_name":"ProNet PPO","plan_name":"PPO","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":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":171835.630,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":171835.630,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":171835.630,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":171835.630,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":171835.630,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":180258.940,"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":261122.760,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":176889.610,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":176889.610,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":176889.610,"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":168466.300,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":176889.610,"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":"Total E&P Mexico","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":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":168466.300,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":22000.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $658089.00, reimbursement will be $9450 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":166613.170,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":28.70,"standard_charge_algorithm":"Reimbursement will be 28.7% 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":"United","plan_name":"SmallGroup","standard_charge_dollar":19840.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $658089.00, reimbursement will be $5250 per diem instead of the contracted 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":171835.630,"methodology":"fee schedule"}]}]},{"description":"Percutaneous skeletal fixation of carpometacarpal dislocation, other than thumb, with manipulation, each joint ","code_information":[{"code":"26676","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":13940.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4653.660,"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":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6788.880,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"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":"34711","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1573.000,"maximum":3384.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3384.000,"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":2600.000,"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":2600.000,"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":2528.000,"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":3057.000,"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":1573.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC ","code_information":[{"code":"002","type":"MS-DRG"},{"code":"02PA0RZ","type":"ICD"}],"standard_charges":[{"setting":"inpatient","minimum":146224.000,"maximum":271072.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":271072.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 20. "},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":146224.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 20. 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pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed) ","code_information":[{"code":"0268T","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":"PENIS, TESTES AND SCROTAL PROCEDURES ","code_information":[{"code":"4832","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6151.890,"maximum":7138.680,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":7138.680,"methodology":"fee schedule"},{"payer_name":"Driscoll Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":6400.450,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":6524.730,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":6524.730,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":6524.730,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":6524.730,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":6214.030,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":6214.030,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":6214.030,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":6214.030,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":6214.030,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":6151.890,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":6338.310,"methodology":"fee schedule"},{"payer_name":"USA MCO","plan_name":"CHIP","standard_charge_dollar":6214.030,"methodology":"fee schedule"}]}]},{"description":"Very long chain fatty acids ","code_information":[{"code":"310","type":"RC"},{"code":"82726","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.920,"maximum":231.150,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":231.150,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":231.150,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":16.920,"methodology":"fee schedule"}]}]},{"description":"Positron emission tomography (PET) imaging; 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(in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1060.150,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":4352.000,"methodology":"case 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14727.450,"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":15605.750,"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":16471.330,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Manipulation, elbow, under anesthesia ","code_information":[{"code":"24300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":587.110,"maximum":3384.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3384.000,"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":2600.000,"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":2600.000,"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":2528.000,"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":3057.000,"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":1573.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":610.830,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":652.340,"methodology":"fee schedule"},{"payer_name":"Molina 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Venipuncture, younger than age 3 years, necessitating the skill of a physician or other qualified health care professional, not to be used for routine venipuncture; femoral or jugular vein ","code_information":[{"code":"36400","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":12814.000,"maximum":12814.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not ","code_information":[{"code":"312","type":"RC"},{"code":"G0481","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":134.170,"maximum":134.170,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":134.170,"methodology":"fee schedule"}]}]},{"description":"Hydroxyprogesterone, 17-d ","code_information":[{"code":"311","type":"RC"},{"code":"83498","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":23.280,"maximum":347.810,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":347.810,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":347.810,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":23.280,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of calcaneal fracture; with manipulation ","code_information":[{"code":"28405","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":91.560,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":366.590,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":500.280,"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":500.280,"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":534.790,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique ","code_information":[{"code":"311","type":"RC"},{"code":"87640","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30.070,"maximum":449.330,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":449.330,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":449.330,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":30.070,"methodology":"fee schedule"}]}]},{"description":"OSTEOMYELITIS WITH CC ","code_information":[{"code":"101","type":"RC"},{"code":"540","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Thoracotomy; with therapeutic wedge resection (eg, mass, nodule), initial ","code_information":[{"code":"32505","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":7614.220,"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":11208.210,"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":11208.210,"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":11876.630,"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":12535.370,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Burr hole(s) or trephine, supratentorial, exploratory, not followed by other surgery ","code_information":[{"code":"362","type":"RC"},{"code":"61250","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s) ","code_information":[{"code":"71551","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":381.400,"maximum":3492.610,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":424.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1668.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3124.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3124.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3308.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3492.610,"methodology":"fee schedule"},{"payer_name":"Driscoll Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":396.810,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":423.780,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":423.780,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":423.780,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":423.780,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":381.400,"methodology":"fee schedule"},{"payer_name":"USA MCO","plan_name":"CHIP","standard_charge_dollar":385.250,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences ","code_information":[{"code":"74183","type":"CPT"},{"code":"921","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":361.600,"maximum":361.600,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":361.600,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of metacarpal fracture, single; without manipulation, each bone ","code_information":[{"code":"26600","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":91.560,"maximum":12814.000,"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":539.350,"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":794.320,"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":794.320,"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":842.260,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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this service in the last 15 months prior to posting. 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rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2115.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":176.300,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Dilation of vagina under anesthesia (other than local) ","code_information":[{"code":"57400","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1141.200,"maximum":13940.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4246.770,"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":5795.590,"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":5795.590,"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":6195.290,"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":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":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1141.200,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"Antinuclear antibodies (ANA); titer ","code_information":[{"code":"319","type":"RC"},{"code":"86039","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.560,"maximum":142.900,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":142.900,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":142.900,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":9.560,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of supracondylar or transcondylar femoral fracture with or without intercondylar extension, with manipulation, with or without skin or skeletal traction ","code_information":[{"code":"27503","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":636.360,"maximum":12814.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":748.660,"methodology":"fee 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schedule","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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Removal of all components of a multi-component, inflatable penile prosthesis without replacement of prosthesis ","code_information":[{"code":"369","type":"RC"},{"code":"54406","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1226.380,"maximum":15613.000,"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":5131.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7003.010,"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":7003.010,"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":7485.980,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1226.380,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"352","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1275.000,"maximum":9100.000,"payers_information":[{"payer_name":"American Health 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"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9100.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $658089.00, reimbursement will be $9450 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":3876.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $658089.00, reimbursement will be $5250 per diem instead of the contracted rate."}]}]},{"description":"Urography, infusion, drip technique and/or bolus technique; with nephrotomography ","code_information":[{"code":"343","type":"RC"},{"code":"74415","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":159.160,"maximum":1102.430,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1102.430,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1102.430,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":159.160,"methodology":"fee schedule"}]}]},{"description":"Hematopoietic progenitor cell (HPC); HPC boost 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logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":3057.000,"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":1573.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":581.560,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":621.080,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":621.080,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":621.080,"methodology":"fee schedule"},{"payer_name":"Molina 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diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Allograft, includes templating, cutting, placement and internal fixation, when performed; osteoarticular, including articular surface and contiguous bone (List separately in addition to code for prima ","code_information":[{"code":"20932","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1022.000,"maximum":12814.000,"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 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transfer, tendon or muscle, hamstrings to femur (eg, Egger's type procedure) ","code_information":[{"code":"27400","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":20821.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10169.310,"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":13878.120,"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":13878.120,"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":14835.240,"methodology":"fee 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","code_information":[{"code":"45114","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1017.000,"maximum":24534.500,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":14902.720,"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":21936.950,"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":21936.950,"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":23245.210,"methodology":"fee 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additiona 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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":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Synovectomy, tendon sheath, radical (tenosynovectomy), flexor tendon, palm and/or finger, each tendon ","code_information":[{"code":"26145","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2434.000,"maximum":2434.000,"payers_information":[{"payer_name":"Healthcare 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rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Totally implantable active middle ear hearing implant; initial placement, including mastoidectomy, placement of and attachment to sound processor ","code_information":[{"code":"0951T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1017.000,"maximum":47078.180,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":28596.170,"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":42093.860,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple 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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 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multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) ","code_information":[{"code":"499","type":"RC"},{"code":"54065","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":760.800,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2758.660,"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":3764.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":760.800,"methodology":"fee 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logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":2528.000,"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":3057.000,"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":1573.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":1151.770,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1230.040,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1230.040,"methodology":"fee 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":9376.840,"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":9376.840,"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":9942.790,"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":10495.880,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"Antibody; Yersinia ","code_information":[{"code":"301","type":"RC"},{"code":"86793","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.300,"maximum":168.820,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":168.820,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":168.820,"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 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rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Amputation, leg, through tibia and fibula; re-amputation ","code_information":[{"code":"27886","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cerebrospinal fluid flow, imaging (not including introduction of material); cisternography ","code_information":[{"code":"619","type":"RC"},{"code":"78630","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":338.430,"maximum":338.430,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":338.430,"methodology":"fee schedule"}]}]},{"description":"Partial laryngectomy (hemilaryngectomy); horizontal ","code_information":[{"code":"31370","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1017.000,"maximum":27728.870,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":16843.040,"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":24793.120,"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":24793.120,"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":26271.710,"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":27728.870,"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":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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(in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":2406.200,"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":3001.050,"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":3591.420,"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 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procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3098.100,"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":3282.860,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3464.940,"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 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rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; common variants (eg, ACMG/ACOG guidelines) ","code_information":[{"code":"307","type":"RC"},{"code":"81220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":476.890,"maximum":5771.940,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":5771.940,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":5771.940,"methodology":"fee 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dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":11253.230,"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":12029.310,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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logic."},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":3537.000,"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":1818.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens 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 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logic."}]}]},{"description":"Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation (includes arthroscopy) ","code_information":[{"code":"29892","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2573.700,"maximum":20821.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10169.310,"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":13878.120,"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":13878.120,"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":14835.240,"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":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":"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case 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","code_information":[{"code":"42400","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":61.780,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":371.600,"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":547.260,"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":547.260,"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":580.290,"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":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 rate","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":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":4352.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":61.780,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":2310.000,"methodology":"case rate"}]}]},{"description":"Blood count; hemoglobin (Hgb) ","code_information":[{"code":"303","type":"RC"},{"code":"85018","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2.030,"maximum":30.380,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":30.380,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":30.380,"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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":2.370,"methodology":"fee schedule"}]}]},{"description":"Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (eg, cyst or ganglion); foot ","code_information":[{"code":"28090","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":636.360,"maximum":13940.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2304.160,"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":3144.500,"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":3144.500,"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":3361.370,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":636.360,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, abdomen; 1 view ","code_information":[{"code":"74018","type":"CPT"},{"code":"740180","type":"CDM"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":106.790,"maximum":229.820,"gross_charge":1806.59,"discounted_cash":1806.59,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":229.820,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":176.590,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":176.590,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":171.710,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":207.660,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":106.790,"methodology":"fee schedule"}]}]},{"description":"Graft (Thiersch operation) for rectal incontinence and/or prolapse ","code_information":[{"code":"46753","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1008.590,"maximum":13940.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3985.110,"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":5438.500,"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":5438.500,"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":5813.570,"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":6165.190,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1008.590,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"111","type":"RC"},{"code":"257","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Bronchoplasty; excision stenosis and anastomosis ","code_information":[{"code":"31775","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":18877.650,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11466.640,"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":16879.010,"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":16879.010,"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":17885.620,"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":18877.650,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"HEART FAILURE AND SHOCK WITH MCC 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":718.270,"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":718.270,"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":767.810,"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":814.250,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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","code_information":[{"code":"24305","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15613.000,"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":4653.660,"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":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6788.880,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":"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":124.780,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Excision, olecranon bursa ","code_information":[{"code":"24105","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1077.390,"maximum":5078.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5078.000,"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":3900.000,"methodology":"case 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Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with destruction of tumor or relief of stenosis by any method other than excision (eg, laser therapy, cryotherapy) ","code_information":[{"code":"31641","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":"REPAIR ARTERIAL BLOCKAGE ","code_information":[{"code":"35475","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":11460.000,"maximum":11460.000,"payers_information":[{"payer_name":"Independent Medical 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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":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":534.790,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case 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rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Mass spectrometry and tandem mass spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen ","code_information":[{"code":"304","type":"RC"},{"code":"83789","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.660,"maximum":250.020,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":250.020,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":250.020,"methodology":"fee 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SPINAL PROCEDURES WITH MCC 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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":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 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","code_information":[{"code":"43113","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":59146.670,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":35926.800,"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":52884.620,"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":52884.620,"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":56038.500,"methodology":"fee 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":19206.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20272.060,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closure of nephrovisceral fistula (eg, renocolic), including visceral repair; thoracic approach ","code_information":[{"code":"360","type":"RC"},{"code":"50526","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":21316.710,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":12948.170,"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":19059.840,"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":19059.840,"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":20196.510,"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":21316.710,"methodology":"fee schedule","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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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":29976.130,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":29976.130,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":31763.820,"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":33525.600,"methodology":"fee schedule","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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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":16.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":18.680,"methodology":"fee schedule"}]}]},{"description":"MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC ","code_information":[{"code":"141","type":"RC"},{"code":"371","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Injection, methylnaltrexone, 0.1 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J2212","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3.470,"maximum":3.470,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3.470,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":3.470,"methodology":"fee schedule"}]}]},{"description":"Burr hole(s) or trephine, infratentorial, unilateral or bilateral ","code_information":[{"code":"61253","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1017.000,"maximum":13468.080,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8180.770,"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":12042.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12042.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12760.330,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13468.080,"methodology":"fee schedule","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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Construction of artificial vagina; without graft ","code_information":[{"code":"57291","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":13940.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":7261.620,"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":9909.970,"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":9909.970,"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":10593.420,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1638.520,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"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":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":297.040,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":297.040,"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":405.370,"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":405.370,"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":433.330,"methodology":"fee schedule","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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Perineogram (eg, vaginogram, for sex determination or extent of anomalies) ","code_information":[{"code":"344","type":"RC"},{"code":"74775","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":234.730,"maximum":662.750,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":662.750,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":662.750,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":234.730,"methodology":"fee schedule"}]}]},{"description":"COMPLICATED PEPTIC ULCER WITH MCC ","code_information":[{"code":"119","type":"RC"},{"code":"380","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"OTHER CEREBROVASCULAR DISORDERS WITH MCC Pediatric","code_information":[{"code":"070","type":"MS-DRG"},{"code":"153","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":28154.000,"maximum":37645.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":28154.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":31902.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":37645.000,"methodology":"case rate"}]}]},{"description":"Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or without di ","code_information":[{"code":"362","type":"RC"},{"code":"50953","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2946.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Lengthening or shortening of flexor or extensor tendon, forearm and/or wrist, single, each tendon ","code_information":[{"code":"25280","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":15613.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4653.660,"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":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6788.880,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care ","code_information":[{"code":"59410","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":13962.390,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8481.020,"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":12484.150,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":12484.150,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13228.660,"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":13962.390,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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 EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC ","code_information":[{"code":"121","type":"RC"},{"code":"154","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"MAJOR HEAD AND NECK PROCEDURES WITH MCC ","code_information":[{"code":"140","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1275.000,"maximum":9100.000,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":1275.000,"methodology":"per diem","additional_payer_notes":"Days 7+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9100.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $658089.00, reimbursement will be $9450 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":3876.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $658089.00, reimbursement will be $5250 per diem instead of the contracted rate."}]}]},{"description":"Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure) ","code_information":[{"code":"329","type":"RC"},{"code":"75774","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":685.770,"maximum":685.770,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":685.770,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":685.770,"methodology":"fee schedule"}]}]},{"description":"Infectious disease (bacterial), quantitative antimicrobial susceptibility reported as phenotypic minimum inhibitory concentration (MIC)\u001a??based antimicrobial susceptibility for each organisms identifi 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","code_information":[{"code":"26471","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4653.660,"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":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6788.880,"methodology":"fee schedule","additional_payer_notes":"The 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procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6788.880,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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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":"RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC ","code_information":[{"code":"169","type":"RC"},{"code":"815","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per 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further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6788.880,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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","code_information":[{"code":"33017","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1017.000,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2011.220,"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":2960.530,"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":2960.530,"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":3137.090,"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":3311.090,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Bio-connekt wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"343","type":"RC"},{"code":"Q4161","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 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1462.780,"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":1563.660,"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":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":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 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logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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":4352.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":2310.000,"methodology":"case rate"}]}]},{"description":"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC ","code_information":[{"code":"10E0XZZ","type":"ICD"},{"code":"121","type":"RC"},{"code":"796","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2344.000,"maximum":5046.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5046.000,"methodology":"case rate","additional_payer_notes":"Days 3+. 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will be 27.3% of billable gross charges instead of the contracted rate."}]}]},{"description":"Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session ","code_information":[{"code":"369","type":"RC"},{"code":"54416","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":54821.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":29875.730,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":40771.590,"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":40771.590,"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":43583.420,"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":46219.510,"methodology":"fee schedule","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":14108.000,"methodology":"case rate","additional_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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":54821.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":29571.000,"methodology":"case rate"}]}]},{"description":"Reduction forehead; contouring only ","code_information":[{"code":"21137","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":877.750,"maximum":5078.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5078.000,"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":3900.000,"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":3900.000,"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":3794.000,"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":4588.000,"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":2360.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens 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 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tendon sheath incision (eg, for trigger finger) ","code_information":[{"code":"26055","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":"Injection, eculizumab, 2 mg ","code_information":[{"code":"344","type":"RC"},{"code":"J1299","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":74.300,"maximum":74.300,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":74.300,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":74.300,"methodology":"fee schedule"}]}]},{"description":"Single energy x-ray absorptiometry (sexa) bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6788.880,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"Excision or destruction lingual tonsil, any method (separate procedure) ","code_information":[{"code":"361","type":"RC"},{"code":"42870","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":13940.000,"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":8245.900,"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":11253.230,"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":11253.230,"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":12029.310,"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":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":12814.000,"methodology":"case 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logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3900.000,"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":3794.000,"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":4588.000,"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":2360.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":16663.400,"methodology":"fee schedule"},{"payer_name":"Molina 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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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Chimeric antigen receptor T-cell (CAR-T) therapy; preparation of blood-derived T lymphocytes for transportation (eg, cryopreservation, storage) 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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 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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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":606.240,"methodology":"fee 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1141.200,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC ","code_information":[{"code":"10E0XZZ","type":"ICD"},{"code":"120","type":"RC"},{"code":"807","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3901.000,"maximum":8399.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":8399.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1883.960,"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":1883.960,"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":2013.880,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14848.360,"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":14848.360,"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":15733.870,"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":16606.550,"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 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further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":5816.000,"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":5816.000,"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":7253.780,"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":8680.750,"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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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6813.630,"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":7283.540,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1139.830,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"Synovectomy, tendon sheath, foot; extensor ","code_information":[{"code":"28088","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":13940.000,"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":4653.660,"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":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6788.880,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); duplication/deletion analysis panel, must include copy number analyses for STRC and DFNB1 deletions in GJB2 and GJB6 gen ","code_information":[{"code":"306","type":"RC"},{"code":"81431","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":679.570,"maximum":7047.140,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":7047.140,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":7047.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":679.570,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":679.570,"methodology":"fee schedule"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition central cannula(e) by sternotomy or thoracotomy, 6 years and older (includes fluoroscopi ","code_information":[{"code":"33964","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3145.000,"maximum":6769.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":6769.000,"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":5198.000,"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":5198.000,"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":5055.000,"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":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately in addition to code for primary procedure) ","code_information":[{"code":"20985","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1022.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) ","code_information":[{"code":"45330","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":140.210,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":719.930,"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":1060.260,"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":1060.260,"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":1124.250,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":4352.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":140.210,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":2310.000,"methodology":"case rate"}]}]},{"description":"Amino acids; single, quantitative, each specimen ","code_information":[{"code":"303","type":"RC"},{"code":"82131","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.690,"maximum":238.300,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":238.300,"methodology":"fee 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13253.550,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Sympathectomy; digital arteries, each digit ","code_information":[{"code":"481","type":"RC"},{"code":"64820","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":708.150,"maximum":13940.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2922.890,"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":3988.890,"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":3988.890,"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":4263.990,"methodology":"fee schedule","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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":708.150,"methodology":"fee 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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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(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":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Independent Medical 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Suture of posterior tibial nerve 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13662.340,"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":14488.700,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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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rate","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 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rate","additional_payer_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":20821.000,"methodology":"case 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","code_information":[{"code":"790","type":"RC"},{"code":"92975","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3110.280,"maximum":12018.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3110.280,"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":4578.360,"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":4578.360,"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":4851.400,"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":5120.490,"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."}]}]},{"description":"Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple ","code_information":[{"code":"44361","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":606.240,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2647.580,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3613.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3613.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3862.350,"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":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 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multiple procedure logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments ","code_information":[{"code":"22808","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":25070.730,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":15228.440,"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":22416.410,"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":22416.410,"methodology":"fee 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dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":4489.660,"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":4489.660,"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":4799.300,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":749.300,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal ","code_information":[{"code":"369","type":"RC"},{"code":"52601","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1812.830,"maximum":20821.000,"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":7193.750,"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":9817.360,"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":9817.360,"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":10494.420,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":20821.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1812.830,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":11042.000,"methodology":"case rate"}]}]},{"description":"Hystscp impacted FB rmvl ","code_information":[{"code":"481","type":"RC"},{"code":"56355","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":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC ","code_information":[{"code":"143","type":"RC"},{"code":"862","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"SPLENIC PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"122","type":"RC"},{"code":"801","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule, cytokeratins 8, 18 & 19, CD45 protein ","code_information":[{"code":"0491U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2435.000,"maximum":2435.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2435.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":2435.000,"methodology":"fee schedule"}]}]},{"description":"Removal of a permanent cardiac contractility modulation-defibrillation system component(s); dual (pacing and defibrillation) transvenous leads only ","code_information":[{"code":"0922T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6186.810,"maximum":15613.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":6186.810,"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":8443.180,"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":8443.180,"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":9025.460,"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":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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"SEIZURES WITH MCC ","code_information":[{"code":"100","type":"MS-DRG"},{"code":"122","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Injection, neostigmine methylsulfate 0.1 mg and glycopyrrolate 0.02 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J2711","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1.400,"maximum":1.400,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1.400,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1.400,"methodology":"fee schedule"}]}]},{"description":"OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W/O CC/MCC Adult","code_information":[{"code":"134","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8931.000,"maximum":11943.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":8931.000,"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":10121.000,"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":11943.000,"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":"Electrocochleography ","code_information":[{"code":"92584","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":234.250,"maximum":1041.620,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":234.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":392.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":392.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":415.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":439.120,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1041.620,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1041.620,"methodology":"fee schedule"}]}]},{"description":"Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracic ","code_information":[{"code":"22212","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of single transvenous electrode, permanent pacemaker or implantable defibrillator ","code_information":[{"code":"33218","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Free osteocutaneous flap with microvascular anastomosis; great toe with web space ","code_information":[{"code":"20973","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":26535.000,"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":13876.630,"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":20436.490,"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":20436.490,"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":21669.970,"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":22875.420,"methodology":"fee schedule","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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":26535.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2573.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":14093.000,"methodology":"case rate"}]}]},{"description":"Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm ","code_information":[{"code":"12015","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":79.770,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":297.040,"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":405.370,"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":405.370,"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":433.330,"methodology":"fee schedule","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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":79.770,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Infectious agent genotype analysis by nucleic acid (DNA or RNA); Hepatitis B virus ","code_information":[{"code":"310","type":"RC"},{"code":"87912","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":220.590,"maximum":3296.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":3296.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":3296.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":220.590,"methodology":"fee schedule"}]}]},{"description":"Liver imaging; with vascular flow ","code_information":[{"code":"400","type":"RC"},{"code":"78202","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":209.950,"maximum":1812.260,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1812.260,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1812.260,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":209.950,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, bone mineral density study, 1 or more sites, axial skeleton (eg, hips, pelvis, spine) ","code_information":[{"code":"739","type":"RC"},{"code":"77078","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":88.620,"maximum":88.620,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":88.620,"methodology":"fee schedule"}]}]},{"description":"SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS ","code_information":[{"code":"029","type":"MS-DRG"},{"code":"132","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"759","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1275.000,"maximum":9465.000,"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":9465.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $658089.00, reimbursement will be $9450 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":3876.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $658089.00, reimbursement will be $5250 per diem instead of the contracted rate."}]}]},{"description":"Radiologic examination, colon, including scout abdominal radiograph(s) and delayed image(s), when performed; single-contrast (eg, barium) study ","code_information":[{"code":"351","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":"Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial ","code_information":[{"code":"362","type":"RC"},{"code":"61320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, foscarbidopa 0.25 mg/foslevodopa 5 mg ","code_information":[{"code":"343","type":"RC"},{"code":"J7356","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1.160,"maximum":1.160,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1.160,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1.160,"methodology":"fee schedule"}]}]},{"description":"Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, mi ","code_information":[{"code":"300","type":"RC"},{"code":"81464","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":512.280,"maximum":3288.510,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3288.510,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":512.280,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":3288.510,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with vein; brachial-ulnar or -radial ","code_information":[{"code":"35523","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1017.000,"maximum":17310.740,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10514.870,"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":15478.000,"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":15478.000,"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":16401.060,"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":17310.740,"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":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Removal of foreign body, upper arm or elbow area; deep (subfascial or intramuscular) ","code_information":[{"code":"24201","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":874.740,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3942.110,"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":5379.820,"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":5379.820,"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":5750.850,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":874.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report ","code_information":[{"code":"930005","type":"CDM"},{"code":"93005","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":118.420,"maximum":320.710,"gross_charge":2019.57,"discounted_cash":2019.57,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":171.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":286.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":286.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":303.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":320.710,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":118.420,"methodology":"fee 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, meropenem (b. braun), not therapeutically equivalent to j2185, 100 mg ","code_information":[{"code":"J2184","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3.340,"maximum":5.500,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":4.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":4.910,"methodology":"fee 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dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":794.320,"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":794.320,"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":842.260,"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":889.110,"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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rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, esophagus, including scout chest radiograph(s) and delayed image(s), when performed; double-contrast (eg, high-density barium and effervescent agent) study 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":2593.530,"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":2748.200,"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":2900.630,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Mediastinoscopy; includes biopsy(ies) of mediastinal mass (eg, lymphoma), when performed ","code_information":[{"code":"39401","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":20821.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8217.310,"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":11214.210,"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":11214.210,"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":11987.600,"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":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":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":270.390,"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":286.750,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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","code_information":[{"code":"319","type":"RC"},{"code":"85362","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.910,"maximum":88.250,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":88.250,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":88.250,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":5.910,"methodology":"fee schedule"}]}]},{"description":"Radical resection of tumor (eg, sarcoma), soft tissue of foot or toe; less than 3 cm ","code_information":[{"code":"28046","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm ","code_information":[{"code":"12014","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":297.040,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":297.040,"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":405.370,"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":405.370,"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":433.330,"methodology":"fee 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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":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); simple ","code_information":[{"code":"369","type":"RC"},{"code":"42960","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":200.900,"maximum":12814.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":236.350,"methodology":"fee 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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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using arterial graft(s), single coronary arterial graft ","code_information":[{"code":"790","type":"RC"},{"code":"S2205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":12814.000,"maximum":25593.120,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":15545.740,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1141.200,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"Suture and/or ligation of thoracic duct; abdominal approach 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9056.450,"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 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","code_information":[{"code":"27265","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":91.560,"maximum":12814.000,"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":366.590,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":500.280,"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":500.280,"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":"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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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":59168.380,"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":62631.160,"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":66093.940,"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":12814.000,"methodology":"case 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procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":5198.000,"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":5055.000,"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":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER RESPIRATORY SYSTEM O.R. 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multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":5771.000,"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":5771.000,"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":5612.000,"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":6788.000,"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":3491.000,"methodology":"case 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procedure logic."},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":2528.000,"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":3057.000,"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":1573.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Genioplasty; augmentation (autograft, allograft, prosthetic material) ","code_information":[{"code":"21120","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":13940.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8245.900,"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":11253.230,"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":11253.230,"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":12029.310,"methodology":"fee 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be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14835.240,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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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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":2600.000,"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":2528.000,"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":3057.000,"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":1573.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens 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"},{"payer_name":"USA MCO","plan_name":"CHIP","standard_charge_dollar":85.320,"methodology":"fee schedule"}]}]},{"description":"Mycophenolate mofetil (myhibbin), oral suspension, 100 mg ","code_information":[{"code":"343","type":"RC"},{"code":"J7514","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3.700,"maximum":3.700,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":3.700,"methodology":"fee schedule"}]}]},{"description":"Percutaneous skeletal fixation of fracture great toe, phalanx or phalanges, with manipulation ","code_information":[{"code":"28496","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":13940.000,"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":4653.660,"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":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6788.880,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC ","code_information":[{"code":"10D00Z1","type":"ICD"},{"code":"112","type":"RC"},{"code":"785","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6337.000,"maximum":13641.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":13641.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":10472.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":10472.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":10187.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":12322.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":6337.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Injection, enfortumab vedotin-ejfv, 0.25 mg ","code_information":[{"code":"344","type":"RC"},{"code":"J9177","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":60.590,"maximum":60.590,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":60.590,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":60.590,"methodology":"fee schedule"}]}]},{"description":"Reconstruction medial collateral ligament, elbow, with tendon graft (includes harvesting of graft) ","code_information":[{"code":"24346","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Insertion of tunneled intraperitoneal catheter for dialysis, open ","code_information":[{"code":"490","type":"RC"},{"code":"49421","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15613.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5285.880,"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":7213.670,"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":7213.670,"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":7711.160,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1235.650,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"Repair inguinal hernia, sliding, any age High Cost Surgery","code_information":[{"code":"360","type":"RC"},{"code":"49525","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":"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC ","code_information":[{"code":"122","type":"RC"},{"code":"629","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"INFLAMMATORY BOWEL DISEASE WITH MCC ","code_information":[{"code":"131","type":"RC"},{"code":"385","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Insertion or replacement of temporary transvenous dual chamber pacing electrodes (separate procedure) High Cost 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","code_information":[{"code":"480","type":"RC"},{"code":"50605","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":"Inj, rimabotulinumtoxinB ","code_information":[{"code":"9018","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":13.250,"maximum":27.910,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":13.400,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":13.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":13.290,"methodology":"fee 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schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":13.290,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":13.290,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":13.290,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":13.290,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":13.290,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":13.290,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":14.490,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":27.510,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":27.910,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":13.690,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":13.950,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":14.090,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":14.090,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":14.090,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":14.090,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":14.090,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13.950,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":20.600,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":13.950,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":13.950,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":13.950,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13.290,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13.550,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13.250,"methodology":"fee 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may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"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":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, sebelipase alfa, 1 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J2840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":891.130,"maximum":891.130,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":891.130,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":891.130,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, lacrimal system ","code_information":[{"code":"360","type":"RC"},{"code":"68899","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":459.830,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":459.830,"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":627.540,"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":627.540,"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":670.820,"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":711.390,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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","drug_information":{"unit":3.500000000000000e+000,"type":"ME"},"code_information":[{"code":"400000","type":"CDM"},{"code":"J9041","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3.100,"maximum":670.040,"gross_charge":8294.83,"discounted_cash":8294.83,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_percentage":42.40,"standard_charge_algorithm":"Reimbursement will be 42.4% 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":"CommercialBaseNetwork","standard_charge_percentage":32.60,"standard_charge_algorithm":"Reimbursement will be 32.6% 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":"Meritain","standard_charge_percentage":32.60,"standard_charge_algorithm":"Reimbursement will be 32.6% 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":"NewBusiness","standard_charge_percentage":31.70,"standard_charge_algorithm":"Reimbursement will be 31.7% 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":38.20,"standard_charge_algorithm":"Reimbursement will be 38.2% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":21.40,"standard_charge_algorithm":"Reimbursement will be 21.4% 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":63.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":93.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":93.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":99.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":104.590,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":3.100,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3.530,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4.170,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":670.040,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":670.040,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC ","code_information":[{"code":"100","type":"RC"},{"code":"754","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Ethmoidectomy; intranasal, total High Cost Surgery","code_information":[{"code":"31201","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":"Chemodenervation of one extremity; 5 or more muscles ","code_information":[{"code":"367","type":"RC"},{"code":"64644","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12814.000,"maximum":12814.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"FRACTURES OF HIP AND PELVIS WITHOUT MCC ","code_information":[{"code":"169","type":"RC"},{"code":"536","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Revision or removal of implanted spinal neurostimulator pulse generator or receiver, with detachable connection to electrode array ","code_information":[{"code":"360","type":"RC"},{"code":"63688","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15613.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":2615.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5352.450,"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":7304.520,"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":7304.520,"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":7808.280,"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":8280.560,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2223.370,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"Excision of pilonidal cyst or sinus; complicated ","code_information":[{"code":"11772","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":874.740,"maximum":13940.000,"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":3942.110,"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":5379.820,"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":5379.820,"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":5750.850,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":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 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adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3988.890,"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":4263.990,"methodology":"fee schedule","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":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":12814.000,"methodology":"case 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contracted rate."}]}]},{"description":"Particle agglutination; screen, each antibody ","code_information":[{"code":"311","type":"RC"},{"code":"86403","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.880,"maximum":130.450,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":130.450,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":130.450,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":9.880,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection and identification, targeted sequence analysis (16S and 18S rRNA genes) with drug-resistance gene 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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 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adjusted for multiple procedure logic."}]}]},{"description":"DECLOT VASCULAR DEVICE ","code_information":[{"code":"36550","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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":"Repair of laceration; conjunctiva, with or without nonperforating laceration sclera, direct closure ","code_information":[{"code":"480","type":"RC"},{"code":"65270","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":"ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES ","code_information":[{"code":"151","type":"RC"},{"code":"278","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Excision of local lesion of epididymis ","code_information":[{"code":"367","type":"RC"},{"code":"54830","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"IMPLANT NEUROELECTRODES ","code_information":[{"code":"361","type":"RC"},{"code":"64577","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":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"ACUTE LEUKEMIA WITH CC 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1462.780,"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":1462.780,"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":1563.660,"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":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 rate","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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":4352.000,"methodology":"case 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":145.090,"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":153.160,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":16.930,"methodology":"fee 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further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":11987.600,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":26535.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":14093.000,"methodology":"case rate"}]}]},{"description":"Complete aa, per square centimeter (add-on, list separately in addition to primary procedure) 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rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":34451.000,"methodology":"case rate","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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infratemporal pre-auricular approach to middle cranial fossa (parapharyngeal space, infratemporal and midline skull base, nasopharynx), with or without disarticulation of the mandible, including parot ","code_information":[{"code":"360","type":"RC"},{"code":"61590","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":41122.410,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":24978.530,"methodology":"fee 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logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3900.000,"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":3794.000,"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":4588.000,"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":2360.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle ","code_information":[{"code":"19307","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":9999.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DRAINAGE OF BLADDER ","code_information":[{"code":"51005","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":"Oscar","plan_name":"HIX","standard_charge_dollar":3675.000,"methodology":"case rate"}]}]},{"description":"Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateral ","code_information":[{"code":"50300","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1017.000,"maximum":17506.660,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10633.870,"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":15653.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":15653.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":16586.680,"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":17506.660,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"von Willebrand factor (VWF), type 2N, factor VIII and VWF binding evaluation, enzyme-linked immunosorbent assays (ELISA), plasma ","code_information":[{"code":"0284U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":17.270,"maximum":17.270,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17.270,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":17.270,"methodology":"fee schedule"}]}]},{"description":"Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos ","code_information":[{"code":"303","type":"RC"},{"code":"89290","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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":149.160,"methodology":"fee schedule"}]}]},{"description":"Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cm ","code_information":[{"code":"11606","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":521.990,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2333.420,"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":3184.430,"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":3184.430,"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":3404.050,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":521.990,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"Percutaneous transluminal pulmonary artery balloon angioplasty; each additional vessel (List separately in addition to code for primary procedure) ","code_information":[{"code":"499","type":"RC"},{"code":"92998","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6041.000,"maximum":43890.000,"payers_information":[{"payer_name":"Curative 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","code_information":[{"code":"369","type":"RC"},{"code":"42104","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":136.060,"maximum":12814.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":160.070,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":766.360,"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":1128.640,"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":1128.640,"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":1196.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1263.330,"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":"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":136.060,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"Tau, total (tTau) ","code_information":[{"code":"307","type":"RC"},{"code":"84394","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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":128.920,"methodology":"fee schedule"}]}]},{"description":"Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm ","code_information":[{"code":"12057","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":153.530,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":543.170,"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":741.260,"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":741.260,"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":792.380,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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general anesthesia ","code_information":[{"code":"27606","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":13940.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4653.660,"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":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6788.880,"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":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 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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"Necropsy (autopsy), gross and microscopic; with brain ","code_information":[{"code":"301","type":"RC"},{"code":"88025","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3613.740,"maximum":3613.740,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":3613.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":3613.740,"methodology":"fee schedule"}]}]},{"description":"Hematopoietic progenitor cell (HPC); HPC boost ","code_information":[{"code":"38243","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":605.860,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":3310.610,"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":4875.620,"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":4875.620,"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":5169.900,"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":5457.490,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":605.860,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"Red cell antigen (Gerbich blood group) genotyping (GE), gene analysis, GYPC (glycophorin C) exons 1-4 ","code_information":[{"code":"0188U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":274.830,"maximum":274.830,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":274.830,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":274.830,"methodology":"fee schedule"}]}]},{"description":"Hemoglobin, quantitative, transcutaneous, per day; methemoglobin ","code_information":[{"code":"303","type":"RC"},{"code":"88741","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.370,"maximum":97.170,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":97.170,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":97.170,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9.370,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9.370,"methodology":"fee schedule"}]}]},{"description":"Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural arrangements ","code_information":[{"code":"0555U","type":"CPT"},{"code":"300","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 schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":759.050,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, mandible; complete, minimum of 4 views ","code_information":[{"code":"409","type":"RC"},{"code":"70110","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":44.310,"maximum":248.150,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":248.150,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":248.150,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":245.180,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":44.310,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":245.180,"methodology":"fee schedule"}]}]},{"description":"Antibody; Helicobacter pylori ","code_information":[{"code":"306","type":"RC"},{"code":"86677","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.430,"maximum":185.730,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":185.730,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":185.730,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":16.850,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":14.430,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":16.850,"methodology":"fee schedule"}]}]},{"description":"Neothelium 4l, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"891","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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC Pediatric","code_information":[{"code":"012","type":"MS-DRG"},{"code":"153","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":57947.000,"maximum":77482.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":57947.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":65663.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":77482.000,"methodology":"case rate"}]}]},{"description":"Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) ","code_information":[{"code":"99292","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":153.870,"maximum":13468.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":13468.000,"methodology":"case rate"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":10341.000,"methodology":"case rate"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":10341.000,"methodology":"case rate"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":10059.000,"methodology":"case rate"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":12165.000,"methodology":"case rate"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":6256.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_percentage":32.40,"standard_charge_algorithm":"Reimbursement will be 32.4% of billable gross charges not to exceed $5917.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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","plan_name":"OpenAccessPlus","standard_charge_percentage":36.20,"standard_charge_algorithm":"Reimbursement will be 36.2% of billable gross charges not to exceed $6704.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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","plan_name":"PPO","standard_charge_percentage":42.70,"standard_charge_algorithm":"Reimbursement will be 42.7% of billable gross charges not to exceed $7911.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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":153.870,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":153.870,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":5136.000,"methodology":"case rate"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed ","code_information":[{"code":"361","type":"RC"},{"code":"37226","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5727.980,"maximum":26059.300,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":6738.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":16844.420,"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":22987.670,"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":22987.670,"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":24573.030,"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":26059.300,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":"MGMCD","standard_charge_dollar":5727.980,"methodology":"fee schedule"}]}]},{"description":"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC ","code_information":[{"code":"141","type":"RC"},{"code":"308","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per 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multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6788.880,"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":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 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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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(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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":2600.000,"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":2600.000,"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":2528.000,"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":3057.000,"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":1573.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10 mev ","code_information":[{"code":"G6012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":592.850,"maximum":3788.410,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":592.850,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":870.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":870.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":923.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":974.730,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":3788.410,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":3788.410,"methodology":"fee schedule"}]}]},{"description":"PERITONEAL ADHESIOLYSIS WITH MCC ","code_information":[{"code":"130","type":"RC"},{"code":"335","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Repair or advancement of profundus tendon, with intact superficialis tendon; secondary without free graft, each tendon ","code_information":[{"code":"26373","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1077.390,"maximum":5078.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5078.000,"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":3900.000,"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":3900.000,"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":3794.000,"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":4588.000,"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":2360.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens 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 MCO","plan_name":"CHIP","standard_charge_dollar":1088.270,"methodology":"fee schedule"}]}]},{"description":"Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with drainage ","code_information":[{"code":"490","type":"RC"},{"code":"67440","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15613.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5316.000,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7254.780,"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":7254.780,"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":7755.110,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1184.020,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"VIRAL MENINGITIS WITHOUT CC/MCC ","code_information":[{"code":"076","type":"MS-DRG"},{"code":"117","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Radical excision external auditory canal lesion; with neck dissection ","code_information":[{"code":"69155","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":21932.260,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":13322.070,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":19610.220,"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":19610.220,"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":20779.720,"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":21932.260,"methodology":"fee schedule","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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC ","code_information":[{"code":"129","type":"RC"},{"code":"690","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"OTHER CEREBROVASCULAR DISORDERS WITH MCC ","code_information":[{"code":"070","type":"MS-DRG"},{"code":"122","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"Provision splnt intracoronal 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","code_information":[{"code":"75743","type":"CPT"},{"code":"922","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":151.320,"maximum":151.320,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":151.320,"methodology":"fee schedule"}]}]},{"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":"490","type":"RC"},{"code":"C7548","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1017.000,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4637.660,"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":5816.000,"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":5816.000,"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":7253.780,"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":8680.750,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Bypass graft, with vein; subclavian-vertebral 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further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC ","code_information":[{"code":"094","type":"MS-DRG"},{"code":"132","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per 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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":5055.000,"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":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"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; third and any 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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 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":6358.870,"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":6358.870,"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":6738.100,"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":7111.820,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":12029.310,"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":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 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2107.930,"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 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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":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Oncology (lung), mRNA, quantitative PCR analysis of 11 genes (BAG1,BRCA1,CDC6, CDK2AP1, ERBB3, FUT3, IL11, LCK, RND3, SH3BGR, WNT3A) and 3 reference genes (ESD, TBP, YAP1), formalin-fixed paraffin emb 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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":5055.000,"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":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"VIRAL ILLNESS WITHOUT MCC 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Zero instances of this service in the last 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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":26849.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":859.610,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":14483.000,"methodology":"case rate"}]}]},{"description":"LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. 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","code_information":[{"code":"40650","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":200.900,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":750.920,"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":1024.790,"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":1024.790,"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":1095.470,"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":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 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schedule","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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":20821.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2969.270,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":11042.000,"methodology":"case rate"}]}]},{"description":"SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC Pediatric","code_information":[{"code":"153","type":"RC"},{"code":"574","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":29240.000,"maximum":39098.000,"payers_information":[{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":29240.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":33134.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":39098.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of temporomandibular 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multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC Pediatric","code_information":[{"code":"272","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":35590.400,"maximum":72869.060,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":35590.400,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $751194.00, charges over the threshold will be paid at 12.7% of billable gross charges in addition to the contracteded rate."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":54962.290,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $751194.00, charges over the threshold will be paid at 18.8% of billable gross charges in addition to the contracteded rate."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":54962.290,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $751194.00, charges over the threshold will be paid at 18.8% of billable gross charges in addition to the contracteded rate."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":63917.020,"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":"PPO","standard_charge_dollar":72869.060,"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."}]}]},{"description":"Blood count; leukocyte (WBC), automated ","code_information":[{"code":"319","type":"RC"},{"code":"85048","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2.170,"maximum":32.460,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":32.460,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":32.460,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2.170,"methodology":"fee schedule"}]}]},{"description":"Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, incl ","code_information":[{"code":"43274","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":13940.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8127.410,"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":11091.530,"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":11091.530,"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":11856.460,"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":12573.580,"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":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 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rate","additional_payer_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":13940.000,"methodology":"case 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","code_information":[{"code":"361","type":"RC"},{"code":"52282","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":13940.000,"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":5131.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7003.010,"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":7003.010,"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":7485.980,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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","code_information":[{"code":"360","type":"RC"},{"code":"44799","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1336.060,"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":1823.330,"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":1823.330,"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":1949.080,"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":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":"Curative 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":13662.340,"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":14488.700,"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":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 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adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":476.180,"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":476.180,"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":504.920,"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":533.010,"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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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":686.270,"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":724.440,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":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 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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 Administrators","plan_name":"COMM","standard_charge_dollar":2012.000,"methodology":"case 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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":4352.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":276.420,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":2310.000,"methodology":"case rate"}]}]},{"description":"Strabismus surgery, recession or resection procedure; 2 or more vertical muscles (excluding superior oblique) ","code_information":[{"code":"67316","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":691.320,"maximum":6769.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":6769.000,"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":5198.000,"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":5198.000,"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":5055.000,"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":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in 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","code_information":[{"code":"739","type":"RC"},{"code":"76873","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":"REPLACE AORTIC VALVE TTHORAC ","code_information":[{"code":"0318T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2625.000,"maximum":2625.000,"payers_information":[{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":2625.000,"methodology":"case rate"}]}]},{"description":"Atrial septectomy or septostomy; closed heart (Blalock-Hanlon type operation) ","code_information":[{"code":"33735","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3145.000,"maximum":6769.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":6769.000,"methodology":"case 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logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Delivery of placenta (separate procedure) ","code_information":[{"code":"361","type":"RC"},{"code":"59414","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":13940.000,"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":4246.770,"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":5795.590,"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":5795.590,"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":6195.290,"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":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":"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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","code_information":[{"code":"26548","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1167.760,"maximum":15613.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":4653.660,"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":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6788.880,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); distal phalanx of finger ","code_information":[{"code":"26236","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":636.360,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2304.160,"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":3144.500,"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":3144.500,"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":3361.370,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":636.360,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, abdomen and pelvis; with contrast material(s) ","code_information":[{"code":"74177","type":"CPT"},{"code":"741770","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":308.960,"maximum":2309.000,"gross_charge":21892.93,"discounted_cash":21892.93,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":2309.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":1771.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":1771.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":1723.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":2085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":1072.000,"methodology":"per diem"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":343.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":935.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1752.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1752.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1855.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1958.890,"methodology":"fee schedule"},{"payer_name":"Driscoll Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":321.440,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":343.290,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":343.290,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":343.290,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":343.290,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":308.960,"methodology":"fee schedule"},{"payer_name":"USA MCO","plan_name":"CHIP","standard_charge_dollar":312.080,"methodology":"fee schedule"}]}]},{"description":"Urinary bladder residual study (List separately in addition to code for primary procedure) ","code_information":[{"code":"322","type":"RC"},{"code":"78730","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":720.820,"maximum":720.820,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":720.820,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":720.820,"methodology":"fee schedule"}]}]},{"description":"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER MAJOR PROCEDURE ","code_information":[{"code":"6314","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":95785.020,"maximum":111149.370,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":111149.370,"methodology":"fee schedule"},{"payer_name":"Driscoll Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":99655.130,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":101590.180,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":101590.180,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":101590.180,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":101590.180,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":96752.550,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":96752.550,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":96752.550,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":96752.550,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":96752.550,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":95785.020,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":98687.600,"methodology":"fee schedule"},{"payer_name":"USA MCO","plan_name":"CHIP","standard_charge_dollar":96752.550,"methodology":"fee schedule"}]}]},{"description":"Radical excision external auditory canal lesion; without neck dissection ","code_information":[{"code":"360","type":"RC"},{"code":"69150","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":13940.000,"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":8245.900,"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":11253.230,"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":11253.230,"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":12029.310,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2096.960,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior) ","code_information":[{"code":"31255","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1613.820,"maximum":13127.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":7514.000,"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":5771.000,"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":5771.000,"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":5612.000,"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":6788.000,"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":3491.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":1679.020,"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":1793.130,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1793.130,"methodology":"fee schedule"},{"payer_name":"Molina 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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 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":3332.820,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"Replacement of integrated neurostimulation system, vagus nerve, including analysis and programming, when performed 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logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"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":"Removal of drug-delivery device(s), intra-articular (List separately in addition to code for primary procedure) ","code_information":[{"code":"20705","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1573.000,"maximum":3384.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3384.000,"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":2600.000,"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":2600.000,"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":2528.000,"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":3057.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure 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logic."},{"payer_name":"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ablation, malignant breast tumor(s), percutaneous, laser, including imaging guidance when performed, unilateral ","code_information":[{"code":"0971T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6509.780,"maximum":13940.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":6509.780,"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":8883.930,"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":8883.930,"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":9496.610,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10071.010,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC ","code_information":[{"code":"101","type":"RC"},{"code":"688","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"INSERT EPIC ELTRD PACE-DEFIB ","code_information":[{"code":"33245","type":"CPT"},{"code":"360","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":"Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use ","code_information":[{"code":"891","type":"RC"},{"code":"90586","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":270.550,"maximum":270.550,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":270.550,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":270.550,"methodology":"fee schedule"}]}]},{"description":"LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC ","code_information":[{"code":"120","type":"RC"},{"code":"418","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Unlisted ultrasound procedure (eg, diagnostic, interventional) ","code_information":[{"code":"344","type":"RC"},{"code":"76999","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":82.520,"maximum":82.520,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":82.520,"methodology":"fee schedule"}]}]},{"description":"Radiopharmaceutical therapy, by intra-articular administration ","code_information":[{"code":"323","type":"RC"},{"code":"79440","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":120.980,"maximum":409.200,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":409.200,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":409.200,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":120.980,"methodology":"fee schedule"}]}]},{"description":"MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND CO ","code_information":[{"code":"111","type":"RC"},{"code":"809","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Prealbumin ","code_information":[{"code":"84134","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":12.510,"maximum":14.590,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14.590,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":12.510,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":14.590,"methodology":"fee schedule"}]}]},{"description":"Curettage or cautery of anal fissure, including dilation of anal sphincter (separate procedure); initial ","code_information":[{"code":"46940","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":158.040,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":782.450,"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":1152.330,"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":1152.330,"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":1221.880,"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":1289.850,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":158.040,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"Transfer of tendon to restore intrinsic function; ring and small finger ","code_information":[{"code":"26497","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1077.390,"maximum":5078.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5078.000,"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":3900.000,"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":3900.000,"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":3794.000,"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":4588.000,"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":2360.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens 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 MCO","plan_name":"CHIP","standard_charge_dollar":1088.270,"methodology":"fee schedule"}]}]},{"description":"HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC ","code_information":[{"code":"157","type":"RC"},{"code":"480","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Injection, pegfilgrastim-jmdb (fulphila), biosimilar, 0.5 mg ","code_information":[{"code":"636","type":"RC"},{"code":"Q5108","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":163.140,"maximum":163.140,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":163.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":163.140,"methodology":"fee schedule"}]}]},{"description":"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"747","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.000,"maximum":22000.000,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":9149.590,"methodology":"fee schedule"},{"payer_name":"Affiliated Healthcare","plan_name":"COMM","standard_charge_percentage":68.00,"standard_charge_algorithm":"Reimbursement will be 68% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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_dollar":9733.610,"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":12015.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":14756.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14756.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":16889.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":9270.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":9270.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":9270.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":19022.410,"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":84.00,"standard_charge_algorithm":"Reimbursement will be 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":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":9177.400,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":9177.400,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":9177.400,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":9177.400,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":9177.400,"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":13123.690,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":11733.190,"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":"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":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":"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":8852.950,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":20810.760,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":8852.950,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":8852.950,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":8852.950,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":8852.950,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":20810.760,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":11979.920,"methodology":"fee schedule"},{"payer_name":"MCM Maxcare","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":"Molina","plan_name":"MGMCR","standard_charge_dollar":10104.410,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":11576.720,"methodology":"fee schedule"},{"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":13919.060,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":10703.260,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":9548.210,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":9733.610,"methodology":"fee schedule"},{"payer_name":"ProNet PPO","plan_name":"PPO","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":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":9455.510,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":9455.510,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":9455.510,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":9455.510,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":9455.510,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":9919.010,"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":14368.660,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":9733.610,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":9733.610,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":9733.610,"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":9270.100,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":9733.610,"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":"Total E&P Mexico","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":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":9270.100,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":22000.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $658089.00, reimbursement will be $9450 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":9168.130,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":28.70,"standard_charge_algorithm":"Reimbursement will be 28.7% 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":"United","plan_name":"SmallGroup","standard_charge_dollar":19840.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $658089.00, reimbursement will be $5250 per diem instead of the contracted 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":9455.510,"methodology":"fee schedule"}]}]},{"description":"Brain imaging, less than 4 static views; ","code_information":[{"code":"402","type":"RC"},{"code":"78600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":184.040,"maximum":1672.270,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1672.270,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1672.270,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":184.040,"methodology":"fee schedule"}]}]},{"description":"TRAUMATIC INJURY WITH MCC ","code_information":[{"code":"169","type":"RC"},{"code":"913","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Clotting; factor VIII, VW factor, ristocetin cofactor ","code_information":[{"code":"85245","type":"CPT"},{"code":"852450","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":19.080,"maximum":242.770,"gross_charge":1462.19,"discounted_cash":1462.19,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":242.770,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":186.620,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":23.130,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":186.620,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":181.300,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":219.280,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":112.850,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":20.810,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":24.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":43.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":64.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":64.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":68.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":22.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":22.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":22.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":72.030,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"NewBusinessNetwork","standard_charge_dollar":62.620,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":71.120,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":83.790,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":22.940,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":22.940,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":22.940,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":22.940,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":22.940,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":45.420,"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 Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":19.850,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":68.820,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":22.940,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":22.940,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":22.940,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":22.940,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":22.940,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":22.940,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":25.000,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":21.200,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":47.490,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":21.200,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":21.200,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":21.200,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":48.170,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":53.910,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":23.630,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":24.090,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":24.320,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":24.320,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":24.320,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":24.320,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":24.320,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":24.090,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":35.560,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":24.090,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":24.090,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":24.090,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":19.080,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":22.940,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":23.400,"methodology":"fee schedule"},{"payer_name":"USA MCO","plan_name":"CHIP","standard_charge_dollar":19.270,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":22.870,"methodology":"fee schedule"}]}]},{"description":"Gradient compression garment, torso/shoulder, custom, each ","code_information":[{"code":"A6569","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":943.900,"maximum":1988.150,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":954.790,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MGMCR","standard_charge_dollar":994.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1038.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1530.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":1530.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":1619.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":946.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":946.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":946.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1709.450,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":946.740,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":946.740,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":946.740,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":946.740,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":946.740,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":1874.550,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"DualEligible","standard_charge_dollar":946.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":946.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":946.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":946.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":946.740,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":946.740,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":1031.950,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":1959.750,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":1988.150,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":975.140,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":994.080,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":1003.540,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":1003.540,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":1003.540,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":1003.540,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":1003.540,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":994.080,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HIX","standard_charge_dollar":1467.450,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":994.080,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":994.080,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":994.080,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":946.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":965.670,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":943.900,"methodology":"fee schedule"}]}]},{"description":"Insertion of Thomas shunt (separate procedure) High Cost Surgery","code_information":[{"code":"360","type":"RC"},{"code":"36835","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":"Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level ","code_information":[{"code":"490","type":"RC"},{"code":"64491","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":12814.000,"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 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logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":5379.820,"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":5750.850,"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":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 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6165.190,"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 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2294.670,"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":2012.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":4352.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":2310.000,"methodology":"case rate"}]}]},{"description":"Insertion of ocular implant secondary; after enucleation, muscles not attached to implant ","code_information":[{"code":"369","type":"RC"},{"code":"65135","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1184.020,"maximum":15613.000,"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":5316.000,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7254.780,"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":7254.780,"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":7755.110,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1184.020,"methodology":"fee 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logic."},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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","code_information":[{"code":"321","type":"RC"},{"code":"77605","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6570.540,"maximum":6570.540,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":6570.540,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":6570.540,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, ankle; complete, minimum of 3 views ","code_information":[{"code":"73610","type":"CPT"},{"code":"920","type":"RC"}],"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":"Craniotomy for repair of encephalocele, skull base ","code_information":[{"code":"360","type":"RC"},{"code":"62121","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":21326.030,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":12953.830,"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":19068.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":19068.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":20205.340,"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":21326.030,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"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":13940.000,"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":4653.660,"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":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6788.880,"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":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 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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":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":14835.240,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2573.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); superficial ","code_information":[{"code":"30801","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":451.360,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2293.880,"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":3130.470,"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":3130.470,"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":3346.360,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":451.360,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"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 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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":"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 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rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2333.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring ","code_information":[{"code":"367","type":"RC"},{"code":"64610","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2946.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; duplication/deletion variants ","code_information":[{"code":"306","type":"RC"},{"code":"81304","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":128.520,"maximum":1555.500,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1555.500,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1555.500,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":150.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":128.520,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":150.000,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, forearm or wrist 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further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Dark field examination, any source (eg, penile, vaginal, oral, skin); includes specimen collection ","code_information":[{"code":"312","type":"RC"},{"code":"87164","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.200,"maximum":137.510,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":137.510,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":137.510,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":9.200,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of 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rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1812.830,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"Hepatic function panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Bilirubin, direct (82248) Phosphatase, alkaline (84075) Protein, total (84155) Transferase, alani ","code_information":[{"code":"302","type":"RC"},{"code":"80076","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6.130,"maximum":104.630,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":104.630,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":104.630,"methodology":"fee 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"160","type":"RC"},{"code":"848","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Filleted finger or toe flap, including preparation of recipient site ","code_information":[{"code":"14350","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":760.800,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2758.660,"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":3764.760,"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":3764.760,"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":4024.400,"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":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":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","additional_payer_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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":760.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"Donor pneumonectomy(s) (including cold preservation), from cadaver donor ","code_information":[{"code":"32850","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1017.000,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":6333.820,"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":9323.450,"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":9323.450,"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":9879.480,"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":10427.440,"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":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Orbital prosthesis ","code_information":[{"code":"367","type":"RC"},{"code":"D5915","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":12814.000,"maximum":12814.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Osteotomy; fibula ","code_information":[{"code":"27707","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":15613.000,"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":4653.660,"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":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":6350.880,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":6788.880,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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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procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":16387.050,"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":17364.330,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":18327.440,"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":12814.000,"methodology":"case 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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":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1139.830,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC 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","code_information":[{"code":"0308T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":9999.000,"maximum":54376.880,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":35148.550,"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":47967.440,"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":47967.440,"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":51275.540,"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":54376.880,"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":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 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Zero instances of this service in the last 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":"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":26849.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":14483.000,"methodology":"case rate"}]}]},{"description":"RHD & RHCE Gnotyp Next-Genrj Seq RH Prox Promoter 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further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Talectomy (astragalectomy) ","code_information":[{"code":"28130","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":12814.000,"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 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logic."},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2360.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens 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 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rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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","code_information":[{"code":"0965T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5513.220,"maximum":8529.270,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5513.220,"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":7523.920,"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":7523.920,"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":8042.810,"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":8529.270,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Complete cycle, gamete intrafallopian transfer (gift), case rate ","code_information":[{"code":"361","type":"RC"},{"code":"S4013","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8496.970,"maximum":13988.660,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":8496.970,"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":12507.630,"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":12507.630,"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":13253.550,"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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laparoscopy, surgical, with ligation of spermatic veins for varicocele ","code_information":[{"code":"360","type":"RC"},{"code":"55550","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2026.810,"maximum":26535.000,"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":8217.310,"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":11214.210,"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":11214.210,"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":11987.600,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":26535.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2026.810,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":14093.000,"methodology":"case rate"}]}]},{"description":"Infectious disease, bacterial vaginosis, quantitative real-time 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further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1883.960,"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":1883.960,"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":2013.880,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":4352.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":365.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":2310.000,"methodology":"case rate"}]}]},{"description":"Laparoscopic repositioning of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including connection to an existing pulse ","code_information":[{"code":"0677T","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":12814.000,"maximum":12814.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"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":"322","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":"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC 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schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":1380.480,"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":1883.960,"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":1883.960,"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":2013.880,"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":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":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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":4352.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":365.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":2310.000,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC ","code_information":[{"code":"153","type":"RC"},{"code":"660","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"description":"Epikeratoplasty ","code_information":[{"code":"361","type":"RC"},{"code":"65767","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":17236.210,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":10469.600,"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":15411.360,"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":15411.360,"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":16330.440,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17236.210,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC Pediatric","code_information":[{"code":"068","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11768.150,"maximum":24094.520,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":11768.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":18173.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":18173.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":21134.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":24094.520,"methodology":"fee schedule"}]}]},{"description":"Revision (including removal) of prosthetic vaginal graft; vaginal approach ","code_information":[{"code":"367","type":"RC"},{"code":"57295","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Decortication, pulmonary (separate procedure); total ","code_information":[{"code":"32220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3145.000,"maximum":13127.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":6769.000,"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":5198.000,"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":5198.000,"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":5055.000,"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":6114.000,"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":3145.000,"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":13127.000,"methodology":"case rate"}]}]},{"description":"Removal of epicranial neurostimulator system ","code_information":[{"code":"0969T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1017.000,"maximum":47078.180,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":28596.170,"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":42093.860,"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":42093.860,"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":44604.210,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":47078.180,"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":2333.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1017.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, wrist; complete, minimum of 3 views ","code_information":[{"code":"359","type":"RC"},{"code":"73110","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":41.920,"maximum":41.920,"payers_information":[{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":41.920,"methodology":"fee schedule"}]}]},{"description":"Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture of 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rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; single perforation ","code_information":[{"code":"44602","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3145.000,"maximum":6769.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":6769.000,"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":5198.000,"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":5198.000,"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":5055.000,"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":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance (eg, proton) imaging, 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rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Arthrotomy, with synovectomy, ankle; including 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rate","additional_payer_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":15613.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1167.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8280.000,"methodology":"case rate"}]}]},{"description":"Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) ","code_information":[{"code":"21188","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":948.000,"maximum":22412.600,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":13613.830,"methodology":"fee 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adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":31746.170,"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":33506.970,"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":"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_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 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be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":5750.850,"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":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":"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm ","code_information":[{"code":"17276","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":143.480,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":799.180,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":1176.970,"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":1176.970,"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":1248.010,"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":1317.430,"methodology":"fee schedule","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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":143.480,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":1022.000,"methodology":"case rate"}]}]},{"description":"Injection, acetaminophen 10 mg and ibuprofen 3 mg ","code_information":[{"code":"343","type":"RC"},{"code":"J0138","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.150,"maximum":0.150,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.150,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":0.150,"methodology":"fee schedule"}]}]},{"description":"Vitrectomy, mechanical, pars plana approach; High Cost 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logic."}]}]},{"description":"Hepatitis c antibody screening, for individual at high risk and other covered indication(s) ","code_information":[{"code":"923","type":"RC"},{"code":"G0472","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":46.350,"maximum":46.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":46.350,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":46.350,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC ","code_information":[{"code":"150","type":"RC"},{"code":"723","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per 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be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":5198.000,"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":5055.000,"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":6114.000,"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":3145.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":992.570,"methodology":"fee 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procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":11987.600,"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":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 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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":20821.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":11042.000,"methodology":"case rate"}]}]},{"description":"Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracolumbar ","code_information":[{"code":"499","type":"RC"},{"code":"63252","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9875.000,"maximum":41467.520,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":25188.160,"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":37077.220,"methodology":"fee 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":23368.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":12606.000,"methodology":"case rate"}]}]},{"description":"Cytopathology, in situ hybridization (eg, FISH), 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","code_information":[{"code":"82330","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":11.720,"maximum":13.680,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.680,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":11.720,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":13.680,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of interphalangeal joint dislocation; requiring anesthesia ","code_information":[{"code":"28665","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":107.150,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":390.690,"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":533.180,"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":533.180,"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":569.950,"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":604.430,"methodology":"fee schedule","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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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 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","code_information":[{"code":"13120","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":232.630,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":844.930,"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":1153.090,"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":1153.090,"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":1232.610,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1307.160,"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 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","code_information":[{"code":"15952","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":12814.000,"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be 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procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Replacement or irrigation, subarachnoid/subdural catheter ","code_information":[{"code":"361","type":"RC"},{"code":"62194","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":708.150,"maximum":13940.000,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":833.110,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2922.890,"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":3988.890,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) 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"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":5281.170,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":5441.210,"methodology":"fee schedule"},{"payer_name":"USA MCO","plan_name":"CHIP","standard_charge_dollar":5334.520,"methodology":"fee schedule"}]}]},{"description":"Injection, azacitidine, 1 mg ","code_information":[{"code":"636","type":"RC"},{"code":"J9025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.760,"maximum":0.760,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":0.760,"methodology":"fee schedule"}]}]},{"description":"Orthopantogram (eg, panoramic x-ray) 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logic."},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":9328.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":20821.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2096.960,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":11042.000,"methodology":"case rate"}]}]},{"description":"Esophagoscopy, flexible, transoral; with removal of foreign body(s) ","code_information":[{"code":"43215","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":606.240,"maximum":12814.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":2647.580,"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":"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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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(in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":3613.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":3613.170,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":3862.350,"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":4095.960,"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":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":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":8580.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":606.240,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4558.000,"methodology":"case rate"}]}]},{"description":"Surgical obturator ","code_information":[{"code":"367","type":"RC"},{"code":"D5931","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":12814.000,"maximum":12814.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study ","code_information":[{"code":"343","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":"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC ","code_information":[{"code":"127","type":"RC"},{"code":"658","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"QHP","standard_charge_dollar":2363.000,"methodology":"per diem"}]}]},{"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":"34704","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":"Rem nonodonto cyst to 1.25cm ","code_information":[{"code":"790","type":"RC"},{"code":"D7460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":12814.000,"maximum":12814.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair round window fistula ","code_information":[{"code":"360","type":"RC"},{"code":"69667","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":951.370,"maximum":13940.000,"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":4452.790,"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":6076.750,"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":6076.750,"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":6495.840,"methodology":"fee schedule","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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":951.370,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculu ","code_information":[{"code":"50561","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1573.000,"maximum":3384.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3384.000,"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":2600.000,"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":2600.000,"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":2528.000,"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":3057.000,"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":1573.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens Health Plan","plan_name":"MCD","standard_charge_dollar":1740.110,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1858.370,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1858.370,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1858.370,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1858.370,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":1672.540,"methodology":"fee schedule"},{"payer_name":"USA MCO","plan_name":"CHIP","standard_charge_dollar":1689.430,"methodology":"fee schedule"}]}]},{"description":"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC A ","code_information":[{"code":"063","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.000,"maximum":33981.790,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":13321.840,"methodology":"fee schedule"},{"payer_name":"Affiliated Healthcare","plan_name":"COMM","standard_charge_percentage":68.00,"standard_charge_algorithm":"Reimbursement will be 68% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 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_dollar":14172.160,"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":19432.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":26411.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":26411.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":29988.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":13497.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPOS","standard_charge_dollar":13497.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRPPO","standard_charge_dollar":13497.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":33563.120,"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":84.00,"standard_charge_algorithm":"Reimbursement will be 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":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13362.330,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13362.330,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":13362.330,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":13362.330,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":13362.330,"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":19108.130,"methodology":"fee schedule"},{"payer_name":"Curative Administrators","plan_name":"COMM","standard_charge_dollar":19159.060,"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":"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":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":"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":12889.920,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":33981.790,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRHMO","standard_charge_dollar":12889.920,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPOS","standard_charge_dollar":12889.920,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRPPO","standard_charge_dollar":12889.920,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCRSNP","standard_charge_dollar":12889.920,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":33981.790,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_dollar":19561.950,"methodology":"fee schedule"},{"payer_name":"MCM Maxcare","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":"Molina","plan_name":"MGMCR","standard_charge_dollar":14712.060,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":18903.570,"methodology":"fee schedule"},{"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":20266.200,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"HIX","standard_charge_dollar":17477.310,"methodology":"fee schedule"},{"payer_name":"Physicians Health Choice","plan_name":"MCR","standard_charge_dollar":13902.220,"methodology":"fee schedule"},{"payer_name":"Prominence Health","plan_name":"MCRHMO","standard_charge_dollar":14172.160,"methodology":"fee schedule"},{"payer_name":"ProNet PPO","plan_name":"PPO","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":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":13767.250,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":13767.250,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":13767.250,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":13767.250,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":13767.250,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":14442.110,"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":20920.810,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCR","standard_charge_dollar":14172.160,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRHMO","standard_charge_dollar":14172.160,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MGMCRPPO","standard_charge_dollar":14172.160,"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":13497.300,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":14172.160,"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":"Total E&P Mexico","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":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13497.300,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11512.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $658089.00, reimbursement will be $9450 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":13348.830,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":28.70,"standard_charge_algorithm":"Reimbursement will be 28.7% 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":"United","plan_name":"SmallGroup","standard_charge_dollar":7093.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $658089.00, reimbursement will be $5250 per diem instead of the contracted 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":13767.250,"methodology":"fee schedule"}]}]},{"description":"Removal of tmj condyle ","code_information":[{"code":"367","type":"RC"},{"code":"D7840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":12814.000,"maximum":12814.000,"payers_information":[{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; 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with manipulation ","code_information":[{"code":"27268","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1573.000,"maximum":3384.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":3384.000,"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":2600.000,"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":2600.000,"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":2528.000,"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":3057.000,"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":1573.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Prostate specific antigen (PSA); 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adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":11987.600,"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":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 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rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":26535.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":14093.000,"methodology":"case rate"}]}]},{"description":"SKIN GRAFTS FOR INJURIES WITH CC/MCC ","code_information":[{"code":"132","type":"RC"},{"code":"904","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2363.000,"maximum":5085.000,"payers_information":[{"payer_name":"Aetna","plan_name":"ASA","standard_charge_dollar":5085.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"CommercialBaseNetwork","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3906.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NewBusiness","standard_charge_dollar":3798.000,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OON","standard_charge_dollar":4594.000,"methodology":"per 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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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"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":13940.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1226.380,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":7397.000,"methodology":"case rate"}]}]},{"description":"Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch 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logic."},{"payer_name":"BCBS","plan_name":"HealthSelectOpenAccess(EPOSOA)","standard_charge_dollar":18689.760,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":19726.380,"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":"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":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12814.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure 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(in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"Meritain","standard_charge_dollar":3005.000,"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":2923.000,"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":3537.000,"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":1818.000,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Driscoll Childrens Health 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procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentialsAccess","standard_charge_dollar":14152.080,"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":14996.060,"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":15827.820,"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 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","code_information":[{"code":"21155","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3675.000,"maximum":29211.920,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":17743.870,"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":26119.160,"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":26119.160,"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":27676.830,"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":29211.920,"methodology":"fee schedule","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":20821.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":11042.000,"methodology":"case rate"}]}]},{"description":"Placement of nephroureteral catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiol ","code_information":[{"code":"499","type":"RC"},{"code":"50433","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1226.380,"maximum":13940.000,"payers_information":[{"payer_name":"BCBS","plan_name":"BlueAdvantage","standard_charge_dollar":5131.520,"methodology":"fee schedule","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"BlueEssentials","standard_charge_dollar":7003.010,"methodology":"fee schedule","additional_payer_notes":"The 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