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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":14030.51,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":14519.28,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15813.07,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":14519.28,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":14519.28,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":14519.28,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":14519.28,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":14519.28,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":14231.76,"methodology":"fee 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schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":25.45,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":88.57,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":82.46,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":27.54,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":119.01,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":129.15,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":153.53,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":25.45,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":25.45,"methodology":"fee 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schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":25.45,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":26.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":25.45,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":25.45,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":26.71,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":26.21,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":35.38,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":23.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":52.17,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":23.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":23.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":23.10,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":69.99,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":24.94,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":69.99,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":26.72,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":26.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":26.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":26.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":26.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":26.98,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":26.72,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":39.45,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":39.45,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":36.90,"methodology":"fee schedule"},{"payer_name":"Superior 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Alliance","plan_name":"Veterans","standard_charge_dollar":76.35,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":25.58,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":25.70,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":33.09,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":26.21,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":26.21,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":26.21,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":26.21,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":26.21,"methodology":"fee 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":6444.19,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":12219.11,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":12219.11,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":5692.72,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11066.46,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":12096.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":12096.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":12096.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":12096.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":12096.92,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":17717.71,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11925.85,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":12341.30,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":13441.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":12341.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":12341.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":12341.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":12341.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":12341.30,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":12096.92,"methodology":"fee 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schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":2281.86,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":2281.86,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":2281.86,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":2281.86,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":2281.86,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":2226.48,"methodology":"fee schedule"}]}]},{"description":"Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease ºCOVID-19»); titer ","code_information":[{"code":"86409","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":78.02,"maximum":431.85,"payers_information":[{"payer_name":"Aetna Better 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":31602.40,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":33904.83,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":33904.83,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":27917.21,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":54270.09,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":33565.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":33565.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":33565.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":33565.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":33565.78,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":49162.00,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":34582.93,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":47724.44,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":40325.42,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":52589.02,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":32853.78,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":32853.78,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":52589.02,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":35939.12,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":33904.83,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":47127.71,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":52011.86,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":38020.39,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":33226.73,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":31682.46,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":35600.07,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 8. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":34582.93,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":34582.93,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":34582.93,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":34582.93,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":34582.93,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":36278.17,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":52552.49,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":52552.49,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":52552.49,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":35600.07,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":35600.07,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":35600.07,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":35600.07,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":35600.07,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":35600.07,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":34243.88,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":33226.73,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":33904.83,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":33091.11,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":34243.88,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":37295.31,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":34243.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":34243.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":34243.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":34243.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":34243.88,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":33565.78,"methodology":"fee schedule"}]}]},{"description":"Non-invasive vagus nerve stimulator ","code_information":[{"code":"E0735","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":46.29,"maximum":143.16,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":50.11,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":47.72,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":47.72,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":47.72,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":47.72,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":47.72,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":47.72,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":47.72,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":47.72,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":69.19,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":47.72,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":47.72,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":47.72,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":46.29,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":49.15,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":66.33,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":97.83,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":46.77,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":50.11,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":50.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":50.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":50.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":50.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":50.58,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":50.11,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":73.97,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":73.97,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":69.19,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":50.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":50.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":50.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":50.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":50.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":50.11,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":46.77,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":143.16,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":47.96,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":48.20,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":62.04,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":49.15,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":49.15,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":49.15,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":49.15,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":49.15,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":47.96,"methodology":"fee schedule"}]}]},{"description":"Non-pneumatic sequential compression garment, trunk ","code_information":[{"code":"E0677","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":76.48,"maximum":236.55,"payers_information":[{"payer_name":"American Health 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schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":114.33,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":78.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":78.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":78.85,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":76.48,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":81.22,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":109.60,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":161.64,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":77.27,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":82.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":83.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":83.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":83.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":83.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":83.58,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":82.79,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":122.22,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":122.22,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":114.33,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":82.79,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":82.79,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":82.79,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":82.79,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":82.79,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":82.79,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":77.27,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":236.55,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":79.24,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":79.64,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":102.50,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":81.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":81.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":81.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":81.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":81.22,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":79.24,"methodology":"fee schedule"}]}]},{"description":"Nonphysician qualified health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes ","code_information":[{"code":"98970","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.67,"maximum":43.32,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":12.51,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":16.08,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":43.19,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":43.32,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":11.91,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":11.91,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":13.62,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":42.93,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":11.91,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":11.91,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":11.91,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":11.91,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":11.91,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":17.27,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":11.91,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":11.91,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":11.91,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":12.27,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":16.55,"methodology":"fee schedule"},{"payer_name":"Molina 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":6508.90,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":11519.02,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":11519.02,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":5749.89,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11177.58,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":11403.83,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":11403.83,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":11403.83,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":11403.83,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":11403.83,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":16702.58,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":11749.40,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":9497.49,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":8025.04,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":10465.58,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":11161.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":11161.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":10465.58,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":12210.16,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":11519.02,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":16011.44,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":10350.72,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":7566.32,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":11288.64,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":6305.03,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":12094.97,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":11749.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":11749.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":11749.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":11749.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":11749.40,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":12325.35,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":17854.48,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":17854.48,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":17854.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":12094.97,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":12094.97,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":12094.97,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":12094.97,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":12094.97,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":12094.97,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":11634.21,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":11288.64,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":11519.02,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11242.56,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":11634.21,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":12670.92,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":11634.21,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":11634.21,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":11634.21,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":11634.21,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":11634.21,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":11403.83,"methodology":"fee schedule"}]}]},{"description":"Power operated vehicle (three or four wheel nonhighway) specify brand name and model number ","code_information":[{"code":"E1230","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":2763.54,"maximum":8547.03,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":2991.46,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":2849.01,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":2849.01,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":2849.01,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":2849.01,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":2849.01,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":2849.01,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":2849.01,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":2849.01,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":4131.06,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":2849.01,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":2849.01,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":2849.01,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":2763.54,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":2934.48,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":3960.12,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":5840.47,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":2792.03,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":2991.46,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":3019.95,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":3019.95,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":3019.95,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":3019.95,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":3019.95,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":2991.46,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":4415.97,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":4415.97,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":4131.06,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":2991.46,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":2991.46,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":2991.46,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":2991.46,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":2991.46,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":2991.46,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":2792.03,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":8547.03,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":2863.26,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":2877.50,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":3703.71,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":2934.48,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":2934.48,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":2934.48,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":2934.48,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":2934.48,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":2863.26,"methodology":"fee schedule"}]}]},{"description":"Power source and control electronics unit for oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, controlled by hardware remote ","code_information":[{"code":"E0490","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":118.49,"maximum":366.45,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":128.26,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":122.15,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":122.15,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":122.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":122.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":122.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":122.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":122.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":122.15,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":177.12,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":122.15,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":122.15,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":122.15,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":118.49,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":125.81,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":169.79,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":250.41,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":119.71,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":128.26,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":129.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":129.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":129.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":129.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":129.48,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":128.26,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":189.33,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":189.33,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":177.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":128.26,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":128.26,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":128.26,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":128.26,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":128.26,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":128.26,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":119.71,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":366.45,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":122.76,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":123.37,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":158.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":125.81,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":125.81,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":125.81,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":125.81,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":125.81,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":122.76,"methodology":"fee schedule"}]}]},{"description":"Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each ","code_information":[{"code":"E2395","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":48.35,"maximum":149.55,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":52.34,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":49.85,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":49.85,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":49.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":49.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":49.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":49.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":49.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":49.85,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":72.28,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":49.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":49.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":49.85,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":48.35,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":51.35,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":69.29,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":102.19,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":48.85,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":52.34,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":52.84,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":52.84,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":52.84,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":52.84,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":52.84,"methodology":"fee 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Texas","plan_name":"POS","standard_charge_dollar":1062.33,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":1062.33,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":1062.33,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":1052.31,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":1553.41,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":1553.41,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":1453.19,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":1052.31,"methodology":"fee schedule"},{"payer_name":"Superior Health 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","code_information":[{"code":"E0193","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":790.73,"maximum":2445.57,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":855.95,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":815.19,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":815.19,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":815.19,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":815.19,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":815.19,"methodology":"fee schedule"},{"payer_name":"Cigna 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":1529.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":2298.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2242.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":25056.22,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":25056.22,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":1292.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2354.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":24805.66,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":24805.66,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":24805.66,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":24805.66,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":24805.66,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":25557.34,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":5623.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":24279.48,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":24279.48,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":26559.59,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":25056.22,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":34828.15,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":24555.10,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":26309.03,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 8. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":25557.34,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":25557.34,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":25557.34,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":25557.34,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":25557.34,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":26810.16,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":26309.03,"methodology":"fee schedule"},{"payer_name":"Superior Health 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":10304.14,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":15604.97,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":15604.97,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":9102.57,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17695.08,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":15448.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":15448.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":15448.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":15448.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":15448.92,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":22627.21,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":15230.45,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":15761.02,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":17165.47,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":15761.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":15761.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":15761.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":15761.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":15761.02,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":15448.92,"methodology":"fee 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schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":66.11,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":66.11,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":83.71,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":83.71,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":83.71,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":13.13,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":15.20,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":59.37,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":45.32,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":43.73,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":14.48,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":14.48,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":50.39,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":46.92,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":15.67,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":68.23,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":74.04,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":88.02,"methodology":"fee schedule"},{"payer_name":"Cigna 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MCD","plan_name":"STAR","standard_charge_dollar":12.16,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":12.16,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":14.48,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":32.58,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":15.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":14.48,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":14.48,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":15.20,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup 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schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":14.91,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":14.91,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":14.91,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":14.91,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":14.55,"methodology":"fee schedule"}]}]},{"description":"Rabies ig, im/sc ","code_information":[{"code":"9133","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":281.95,"maximum":863.12,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":302.09,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":287.71,"methodology":"fee 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of Texas","plan_name":"PFFS","standard_charge_dollar":304.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":304.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":304.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":304.97,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":302.09,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":445.95,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":445.95,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":417.18,"methodology":"fee schedule"},{"payer_name":"Superior Health 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":87165.40,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":116109.60,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":116109.60,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":79558.84,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":176345.70,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":114948.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":114948.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":114948.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":114948.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":114948.50,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":168358.92,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":118431.79,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":188100.71,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":158938.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":207273.90,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":112510.20,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":112510.20,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":207273.90,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":123076.18,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":116109.60,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":161392.34,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":204999.11,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":27.70,"standard_charge_algorithm":"Reimbursement will be 27.7% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":113787.41,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":23.10,"standard_charge_algorithm":"Reimbursement will be 23.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":121915.08,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 23. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":118431.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":118431.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":118431.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":118431.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":118431.79,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":124237.27,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":179969.88,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":179969.88,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":179969.88,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":121915.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":121915.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":121915.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":121915.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":121915.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":121915.08,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":117270.70,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":113787.41,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":116109.60,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":113322.97,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":117270.70,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":127720.56,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":117270.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":117270.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":117270.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":117270.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":117270.70,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":114948.50,"methodology":"fee schedule"}]}]},{"description":"Traction frame, attached to footboard, extremity traction, (e.g., buck's) ","code_information":[{"code":"E0870","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":153.95,"maximum":476.13,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":166.65,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":158.71,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":158.71,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":158.71,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":158.71,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":158.71,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":158.71,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":158.71,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":158.71,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":230.13,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":158.71,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":158.71,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":158.71,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":153.95,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":163.47,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":220.61,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":325.36,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":155.54,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":166.65,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":168.23,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":168.23,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":168.23,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":168.23,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":168.23,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":166.65,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":246.00,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":246.00,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":230.13,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":166.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":166.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":166.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":166.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":166.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":166.65,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":155.54,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":476.13,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":159.50,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":160.30,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":206.32,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":163.47,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":163.47,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":163.47,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":163.47,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":163.47,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":159.50,"methodology":"fee schedule"}]}]},{"description":"Transcutaneous electrical joint stimulation device system, includes all accessories ","code_information":[{"code":"E0762","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be 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Healthcare","plan_name":"HIX","standard_charge_dollar":261.44,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":124.98,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":133.91,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":135.18,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":135.18,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":135.18,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":135.18,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":135.18,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":133.91,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":197.67,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":197.67,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":184.92,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":133.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":133.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":133.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":133.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":133.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":133.91,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":124.98,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":382.59,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":128.17,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":128.81,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":165.79,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":131.36,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":131.36,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":131.36,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":131.36,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":131.36,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":128.17,"methodology":"fee schedule"}]}]},{"description":"Transfer of an orthosis from one shoe to another, caliper plate, new ","code_information":[{"code":"L3610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":115.27,"maximum":954.91,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":124.78,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":118.84,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":118.84,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":118.84,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":118.84,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":118.84,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":118.84,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":118.84,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":118.84,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":172.32,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":118.84,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":954.91,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":118.84,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":118.84,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":954.91,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":115.27,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":122.41,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":165.19,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":243.62,"methodology":"fee 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13085.47,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":13541.31,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":14747.96,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":13541.31,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":13541.31,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":13541.31,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":13541.31,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":13541.31,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13273.17,"methodology":"fee schedule"}]}]},{"description":"Trauma Response with Crit ","code_information":[{"code":"5045","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1264.34,"maximum":3870.44,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":1354.65,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":1290.15,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":1290.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1290.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":1290.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":1290.15,"methodology":"fee schedule"},{"payer_name":"Cigna 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Healthcare","plan_name":"HIX","standard_charge_dollar":2644.80,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":1264.34,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":1354.65,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":1367.56,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":1367.56,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":1367.56,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":1367.56,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":1367.56,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":1354.65,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":1999.73,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":1999.73,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":1870.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":1354.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":1354.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":1354.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":1354.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":1354.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":1354.65,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":1264.34,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":3870.44,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1296.60,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":1303.05,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":1677.19,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":1328.85,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":1328.85,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":1328.85,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":1328.85,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":1328.85,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":1296.60,"methodology":"fee schedule"}]}]},{"description":"TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC ","code_information":[{"code":"083","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":43576.00,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":17636.03,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":11294.98,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":16796.22,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":16796.22,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":9977.86,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":19396.61,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":16628.26,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":16628.26,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":16628.26,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":16628.26,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":16628.26,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":24354.52,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":17132.14,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":18509.06,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":15639.48,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":20395.70,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":16275.54,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":16275.54,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":20395.70,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":17803.99,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":16796.22,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":23346.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":20171.86,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":14745.52,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":16460.30,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":12287.47,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":17636.03,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":17132.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":17132.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":17132.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":17132.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":17132.14,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":17971.96,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":26034.14,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":26034.14,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":26034.14,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":17636.03,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":17636.03,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":17636.03,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":17636.03,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":17636.03,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":17636.03,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":16964.18,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":16460.30,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":16796.22,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":43576.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16393.11,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":17084.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":41244.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":29786.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":16964.18,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":18475.84,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":16964.18,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":16964.18,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":16964.18,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":16964.18,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":16964.18,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":16628.26,"methodology":"fee schedule"}]}]},{"description":"Treprostinil injection ","code_information":[{"code":"1701","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":54.70,"maximum":167.44,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":58.61,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":55.81,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":55.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":55.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":55.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":55.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":55.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":55.81,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":80.93,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":55.81,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":55.81,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":55.81,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":57.49,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":77.58,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":114.42,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":54.70,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":58.61,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":59.16,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":59.16,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":59.16,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":59.16,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":59.16,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":58.61,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":86.51,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":86.51,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":80.93,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":58.61,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":58.61,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":58.61,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":58.61,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":58.61,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":58.61,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":54.70,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":167.44,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":56.09,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":56.37,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":72.56,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":57.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":57.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":57.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":57.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":57.49,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":56.09,"methodology":"fee schedule"}]}]},{"description":"Trimethylamine/trimethylamine N-oxide (TMA/TMAO) profile, tandem mass spectrometry (MS/MS), urine, with algorithmic analysis and interpretive report ","code_information":[{"code":"0256U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":72.81,"maximum":966.40,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":167.95,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":98.85,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":75.46,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":72.81,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":159.95,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":159.95,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":83.90,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":78.12,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":749.11,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":812.93,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":966.40,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":159.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":159.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":159.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":159.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":159.95,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":231.93,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":159.95,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":159.95,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":159.95,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup 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schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":403.63,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":50.24,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":50.24,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":403.63,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":48.73,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":51.75,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":69.83,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":102.99,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":49.24,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":52.75,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":53.25,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":53.25,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":53.25,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":53.25,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":53.25,"methodology":"fee schedule"},{"payer_name":"Shared 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Healthcare","plan_name":"HIX","standard_charge_dollar":345.94,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":155.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":155.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":155.10,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":464.06,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":165.38,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":464.06,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":177.19,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":178.88,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":178.88,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":178.88,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":178.88,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":178.88,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":177.19,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":261.56,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":261.56,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":244.69,"methodology":"fee 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schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":169.59,"methodology":"fee schedule"}]}]},{"description":"CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC ","code_information":[{"code":"846","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":40091.46,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":27158.73,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":25865.46,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":25865.46,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":25606.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":25606.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":25606.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":25606.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":25606.81,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":37504.92,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  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schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":4.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":4.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":4.74,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":4.62,"methodology":"fee schedule"}]}]},{"description":"CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC ","code_information":[{"code":"416","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":25791.26,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":17471.50,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":10398.44,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":16639.52,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":16639.52,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":9491.01,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":21037.24,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":16473.12,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":16473.12,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":16473.12,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":16473.12,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":16473.12,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":24127.30,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16240.17,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":16805.92,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":18303.47,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":16805.92,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":16805.92,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":16805.92,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":16805.92,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":16805.92,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":16473.12,"methodology":"fee 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schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":255.30,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":255.30,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":255.30,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":323.27,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":323.27,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":323.27,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":50.71,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":58.68,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":229.15,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":174.94,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":168.79,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":55.89,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":55.89,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":194.50,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":181.08,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":60.49,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":261.88,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":284.19,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":337.84,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":55.89,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":55.89,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":55.89,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":55.89,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":55.89,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":81.04,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":46.95,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":46.95,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":46.95,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":46.95,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":55.89,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":155.23,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":57.50,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":55.89,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":55.89,"methodology":"fee schedule"},{"payer_name":"Humana 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schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":54.77,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":153.70,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":58.68,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":59.24,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":59.24,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":59.24,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":59.24,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":59.24,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":58.68,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":86.63,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":86.63,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":81.04,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":58.68,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":58.68,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":58.68,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":58.68,"methodology":"fee schedule"},{"payer_name":"Superior Health 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schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":57.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":57.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":57.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":57.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":57.57,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":56.17,"methodology":"fee schedule"}]}]},{"description":"Chromosome analysis, in situ for amniotic fluid cells, count cells from 6-12 colonies, 1 karyotype, with banding ","code_information":[{"code":"88269","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":145.87,"maximum":1086.20,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":1086.20,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":1086.20,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":1086.20,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":855.23,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":855.23,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":855.23,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":793.20,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":793.20,"methodology":"fee 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schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":173.66,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":173.66,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":604.34,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":562.66,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":187.95,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":812.61,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":881.84,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1048.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":173.66,"methodology":"fee 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":57919.94,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":66890.27,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":66890.27,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":52865.51,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":117178.74,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":79037.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 11. "},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":85612.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 11. "},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":101826.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 11. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":66221.37,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":66221.37,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":66221.37,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":66221.37,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":66221.37,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":96990.89,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":50701.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 8. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":68228.08,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":104051.75,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":87919.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":114657.79,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":64816.67,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":64816.67,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":114657.79,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":70903.69,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":66890.27,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":92977.48,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":113399.44,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":82894.37,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":65552.46,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":69076.04,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":70234.78,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 11. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":68228.08,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":68228.08,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":68228.08,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":68228.08,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":68228.08,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":71572.59,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":103679.92,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":103679.92,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":103679.92,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":70234.78,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":70234.78,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":70234.78,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":70234.78,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":70234.78,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":70234.78,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":67559.17,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":65552.46,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":66890.27,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":61194.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 9. "},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":65284.90,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":45416.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 9. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":57920.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 9. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":41830.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 9. "},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":67559.17,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":73579.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":67559.17,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":67559.17,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":67559.17,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":67559.17,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":67559.17,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":66221.37,"methodology":"fee schedule"}]}]},{"description":"CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE ","code_information":[{"code":"325","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":43818.17,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":20295.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":20295.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":20295.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":15968.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":15968.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":15968.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":14816.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":14816.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":14816.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":18785.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":18785.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":18785.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":29683.28,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":28269.79,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":28269.79,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":27987.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":27987.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":27987.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":27987.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":27987.09,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":40991.20,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":28835.19,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":38101.81,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":32194.64,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":41985.54,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":27393.43,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":27393.43,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":41985.54,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":29965.98,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":28269.79,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":39295.01,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":41524.76,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":30354.37,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":27704.39,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":25294.36,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":29683.28,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":28835.19,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":28835.19,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":28835.19,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":28835.19,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":28835.19,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":30248.68,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":43818.17,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":43818.17,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":43818.17,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":29683.28,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":29683.28,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":29683.28,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":29683.28,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":29683.28,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":29683.28,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":28552.49,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":27704.39,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":28269.79,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":27591.32,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":28552.49,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":31096.77,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":28552.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":28552.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":28552.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":28552.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":28552.49,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":27987.09,"methodology":"fee schedule"}]}]},{"description":"Covid-19 convalescent pla ","code_information":[{"code":"9540","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":480.33,"maximum":1470.39,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":514.64,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":490.13,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":490.13,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":490.13,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":490.13,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":490.13,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":490.13,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":490.13,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":710.69,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":490.13,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":490.13,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":490.13,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":504.83,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":681.28,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":1004.77,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":480.33,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":514.64,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":519.54,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":519.54,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":519.54,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":519.54,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":519.54,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":514.64,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":759.70,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":759.70,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":710.69,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":514.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":514.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":514.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":514.64,"methodology":"fee schedule"},{"payer_name":"Superior Health 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schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":79.69,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":79.69,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":74.55,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":53.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":53.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":53.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":53.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":53.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":53.98,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":50.38,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":154.23,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":51.67,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":51.93,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":66.83,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":52.95,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":52.95,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":52.95,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":52.95,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":52.95,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":51.67,"methodology":"fee schedule"}]}]},{"description":"DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC ","code_information":[{"code":"294","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":24071.70,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":16306.64,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":10780.65,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":15530.13,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":15530.13,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":9523.51,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":18513.37,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":15374.83,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":15374.83,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":15374.83,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":15374.83,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":15374.83,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":22518.69,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":15840.73,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":16347.03,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":13812.65,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":18013.29,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":15048.70,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":15048.70,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":18013.29,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":16461.94,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":15530.13,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":21586.88,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":17815.60,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":13023.11,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":15219.53,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":10852.18,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":16306.64,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":15840.73,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":15840.73,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":15840.73,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":15840.73,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":15840.73,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":16617.24,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":24071.70,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":24071.70,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":24071.70,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":16306.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":16306.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":16306.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":16306.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":16306.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":16306.64,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":15685.43,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":15219.53,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":15530.13,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":15157.41,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":15685.43,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":17083.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":15685.43,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":15685.43,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":15685.43,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":15685.43,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":15685.43,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":15374.83,"methodology":"fee schedule"}]}]},{"description":"DENTAL AND ORAL DISEASES WITH CC ","code_information":[{"code":"158","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":20598.76,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":13954.00,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":7565.28,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":13289.52,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":13289.52,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":6683.08,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12991.69,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13156.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13156.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":13156.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":13156.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":13156.62,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":19269.80,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":13555.31,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":12520.88,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":10579.68,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":13797.14,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":12877.54,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":12877.54,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":13797.14,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":14086.89,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":13289.52,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":18472.43,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":13645.71,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":9974.94,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":13023.73,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":8312.14,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":13954.00,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":13555.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":13555.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":13555.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":13555.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":13555.31,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":14219.79,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":20598.76,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":20598.76,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":20598.76,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":13954.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":13954.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":13954.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":13954.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":13954.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":13954.00,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":13422.42,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13023.73,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13289.52,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12970.57,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":13422.42,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":14618.47,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":13422.42,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":13422.42,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":13422.42,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":13422.42,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":13422.42,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13156.62,"methodology":"fee 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IPA","plan_name":"MCR","standard_charge_dollar":13.68,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":18.46,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":12.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":27.22,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":12.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":12.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":12.10,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":36.52,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":13.01,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":36.52,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":13.94,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":14.08,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":14.08,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":14.08,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":14.08,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":14.08,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13.94,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":20.58,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":20.58,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":19.26,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":13.94,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":13.94,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":13.94,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":13.94,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":13.94,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":13.94,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":12.65,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13.01,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":39.84,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13.35,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":13.41,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":17.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":13.68,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":13.68,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":13.68,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":13.68,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":13.68,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13.35,"methodology":"fee schedule"}]}]},{"description":"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC ","code_information":[{"code":"438","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":29339.11,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":19874.88,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":13427.91,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":18928.46,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":18928.46,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":11862.07,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":23059.45,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":18739.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":18739.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":18739.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":18739.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":18739.18,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":27446.27,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":18474.18,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":19117.74,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":20821.31,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":19117.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":19117.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":19117.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":19117.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":19117.74,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":18739.18,"methodology":"fee 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schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":625.76,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":625.76,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":625.76,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":792.35,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":792.35,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":792.35,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":143.85,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":561.70,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":428.81,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":413.74,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":137.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":137.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":476.76,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":443.88,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":641.20,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":695.82,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":827.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":137.00,"methodology":"fee schedule"},{"payer_name":"Cigna 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IPA","plan_name":"MCR","standard_charge_dollar":141.11,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":190.43,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":280.85,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":376.75,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":134.26,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":376.75,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":143.85,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":145.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":145.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":145.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":145.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":145.22,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":143.85,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":212.35,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":212.35,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":198.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":143.85,"methodology":"fee schedule"},{"payer_name":"Superior 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schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":34.83,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":37.32,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":37.67,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":37.67,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":37.67,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":37.67,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":37.67,"methodology":"fee schedule"},{"payer_name":"Shared 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schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":37.32,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":34.83,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":106.62,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":35.72,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":35.90,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":46.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":36.61,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":36.61,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":36.61,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":36.61,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":36.61,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":35.72,"methodology":"fee schedule"}]}]},{"description":"Emergency hand pump for use with electric or electric/pneumatic ventricular assist device, replacement only ","code_information":[{"code":"Q0494","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":246.62,"maximum":2042.87,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":266.96,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":254.25,"methodology":"fee 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":18424.72,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":19066.57,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":20765.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":19066.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":19066.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":19066.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":19066.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":19066.57,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":18689.01,"methodology":"fee 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schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":101.27,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":101.27,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":101.27,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":128.23,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":128.23,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":128.23,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":20.11,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":23.28,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":90.90,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":69.39,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":66.95,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":22.17,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":22.17,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":77.15,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":71.83,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":23.99,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":103.18,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":111.98,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":133.11,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":22.17,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":22.17,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":22.17,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":22.17,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":22.17,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":32.15,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":18.62,"methodology":"fee schedule"},{"payer_name":"Community Health Choice 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schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":25689.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":25689.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":25689.49,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":25432.59,"methodology":"fee schedule"}]}]},{"description":"BURNS; M > 0 ","code_information":[{"code":"A2101","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":19217.88,"maximum":39665.38,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":20824.33,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":19832.69,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":19634.36,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":19634.36,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":19634.36,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":19634.36,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":19634.36,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":19217.88,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":19217.88,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":21022.65,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":19436.04,"methodology":"fee schedule"},{"payer_name":"Superior Health 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schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":19356.71,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":19832.69,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":19832.69,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":19832.69,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":19832.69,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":19832.69,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":19634.36,"methodology":"fee schedule"}]}]},{"description":"CARDIAC; M < 31.15 ","code_information":[{"code":"A1404","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":28458.83,"maximum":58738.56,"payers_information":[{"payer_name":"American Health 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schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":29369.28,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":29075.59,"methodology":"fee schedule"}]}]},{"description":"CARDIAC; M > 38.55 & M < 48.85 ","code_information":[{"code":"A1402","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":18981.74,"maximum":39177.99,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":20568.45,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":19589.00,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":19393.11,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":19393.11,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":19393.11,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":19393.11,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":19393.11,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":18981.74,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":18981.74,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":20764.34,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":19197.22,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":19589.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":19589.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":19589.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":19589.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":19589.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":19589.00,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":19589.00,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":39177.99,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":19118.86,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":19589.00,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":19589.00,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":19589.00,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":19589.00,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":19589.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":19393.11,"methodology":"fee schedule"}]}]},{"description":"DEPRESSIVE NEUROSES ","code_information":[{"code":"881","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1009.00,"maximum":18971.37,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":13737.89,"methodology":"fee 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":1193.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":1339.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1215.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":13083.70,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":13083.70,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":1009.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1463.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":12952.86,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":12952.86,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":12952.86,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":12952.86,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":12952.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":18971.37,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":13345.37,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":12169.41,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":10282.71,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":13409.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":12678.11,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":12678.11,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":13409.85,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":13868.72,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":13083.70,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":18186.34,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":13262.68,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":9694.94,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":12822.03,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":8078.82,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":13737.89,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":13345.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":13345.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":13345.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":13345.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":13345.37,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13999.56,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":13737.89,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":13737.89,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":13737.89,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":13737.89,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":13737.89,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":13737.89,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":13214.54,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13083.70,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12769.69,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":13214.54,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":14392.07,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":13214.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":13214.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":13214.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":13214.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":13214.54,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":12952.86,"methodology":"fee 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","code_information":[{"code":"26205","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2686.34,"maximum":7415.64,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":3153.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7415.64,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2775.30,"methodology":"fee 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charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee 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Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":5812.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":5928.24,"methodology":"fee schedule"}]}]},{"description":"HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS ","code_information":[{"code":"4224","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":13157.50,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":12210.91,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":11052.30,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":11052.30,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":11052.30,"methodology":"fee schedule"},{"payer_name":"Community 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of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":10526.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":10736.52,"methodology":"fee schedule"}]}]},{"description":"Incision and drainage of Bartholin's gland abscess ","code_information":[{"code":"56420","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":78.98,"maximum":206.55,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":78.98,"methodology":"fee 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charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":6083.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":6204.66,"methodology":"fee schedule"}]}]},{"description":"Insertion of breast implant on same day of mastectomy (ie, immediate) 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multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":10005.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":11899.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2686.34,"methodology":"fee 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schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":5421.20,"methodology":"fee schedule"}]}]},{"description":"MINOR SKIN DISORDERS WITH MCC ","code_information":[{"code":"606","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":28690.21,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":19435.30,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":12707.69,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":18509.81,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":18509.81,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":11225.83,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":21822.63,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":18324.71,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":18324.71,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":18324.71,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":18324.71,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":18324.71,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":26839.22,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":18065.57,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":18694.91,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":20360.79,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":18694.91,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":18694.91,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":18694.91,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":18694.91,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":18694.91,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":18324.71,"methodology":"fee 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schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":42.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":61.63,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":42.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":42.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":42.51,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":43.78,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":59.08,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":87.14,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":41.65,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":44.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":45.06,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":45.06,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":45.06,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":45.06,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":45.06,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":44.63,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":65.88,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":65.88,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":61.63,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":44.63,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":44.63,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":44.63,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":44.63,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":44.63,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":44.63,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":41.65,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":127.52,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":42.72,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":42.93,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":55.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":43.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":43.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":43.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":43.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":43.78,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":42.72,"methodology":"fee schedule"}]}]},{"description":"Mmrv vaccine sc ","code_information":[{"code":"9011","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":130.04,"maximum":398.07,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":139.32,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":132.69,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":132.69,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":132.69,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":132.69,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":132.69,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":132.69,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":132.69,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":192.40,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":132.69,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":132.69,"methodology":"fee 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Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":140.65,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":140.65,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":140.65,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":139.32,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":205.67,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":205.67,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":192.40,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":139.32,"methodology":"fee schedule"},{"payer_name":"Superior Health 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or melt curve analysis) ACADM (acyl-CoA dehydrogenase ","code_information":[{"code":"81400","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":53.73,"maximum":400.06,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":400.06,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":400.06,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":400.06,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":314.99,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":314.99,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":314.99,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":292.15,"methodology":"fee 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Health","plan_name":"MGMCR","standard_charge_dollar":19.69,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":29.06,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":29.06,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":27.19,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":19.69,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":19.69,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":19.69,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":19.69,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":19.69,"methodology":"fee 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schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":19.31,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":19.31,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":19.31,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":19.31,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":18.84,"methodology":"fee schedule"}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. 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"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":43185.35,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":43185.35,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":42753.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":42753.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":42753.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":42753.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":42753.50,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":62618.76,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":42148.90,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":43617.20,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":47503.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":43617.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":43617.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":43617.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":43617.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":43617.20,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":42753.50,"methodology":"fee 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Plan","plan_name":"MCRHMO","standard_charge_dollar":69.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":69.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":69.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":69.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":69.48,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":64.85,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":198.51,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":66.50,"methodology":"fee schedule"},{"payer_name":"Van Lang 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schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":1123.75,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":1051.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":761.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":761.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":761.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":761.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":761.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":761.25,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":710.50,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":2175.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":728.62,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":732.25,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":942.50,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":746.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":746.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":746.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":746.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":746.75,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":728.62,"methodology":"fee schedule"}]}]},{"description":"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC ","code_information":[{"code":"099","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":26069.19,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":17659.77,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":11781.57,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":16818.83,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":16818.83,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":10407.71,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20232.22,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":16650.64,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":16650.64,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":16650.64,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":16650.64,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":16650.64,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":24387.30,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":17155.21,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":18547.67,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":15672.11,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":20438.24,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":16297.45,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":16297.45,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":20438.24,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":17827.96,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":16818.83,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":23378.17,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":20213.94,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":14776.28,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":16482.45,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":12313.10,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":17659.77,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":17155.21,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":17155.21,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":17155.21,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":17155.21,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":17155.21,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":17996.15,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":26069.19,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":26069.19,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":26069.19,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":17659.77,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":17659.77,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":17659.77,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":17659.77,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":17659.77,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":17659.77,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":16987.02,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":16482.45,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":16818.83,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16415.18,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":16987.02,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":18500.71,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":16987.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":16987.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":16987.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":16987.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":16987.02,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":16650.64,"methodology":"fee schedule"}]}]},{"description":"NON-MALIGNANT BREAST DISORDERS WITH CC/MCC ","code_information":[{"code":"600","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":20800.57,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":14090.71,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":8377.95,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":13419.72,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":13419.72,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":7400.99,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14387.26,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13285.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13285.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":13285.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":13285.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":13285.52,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":19458.59,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":13688.11,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":12743.20,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":10767.54,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":14042.12,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":13003.71,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":13003.71,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":14042.12,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":14224.90,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":13419.72,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":18653.41,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":13888.01,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":10152.06,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":13151.33,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":8459.73,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":14090.71,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":13688.11,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":13688.11,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":13688.11,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":13688.11,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":13688.11,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":14359.10,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":20800.57,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":20800.57,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":20800.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":14090.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":14090.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":14090.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":14090.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":14090.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":14090.71,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":13553.92,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13151.33,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13419.72,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13097.65,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":13553.92,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":14761.69,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":13553.92,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":13553.92,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":13553.92,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":13553.92,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":13553.92,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13285.52,"methodology":"fee schedule"}]}]},{"description":"Non-pneumatic, non-sequential, peristaltic wave compression pump ","code_information":[{"code":"E0683","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":75.72,"maximum":234.18,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":81.96,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":78.06,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":78.06,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":78.06,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":78.06,"methodology":"fee schedule"},{"payer_name":"Cigna 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Health","plan_name":"MGMCR","standard_charge_dollar":21.90,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":32.33,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":32.33,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":30.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":21.90,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":21.90,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":21.90,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":21.90,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":21.90,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":21.90,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":19.55,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":20.44,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":62.58,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":20.96,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":21.07,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":27.12,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":21.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":21.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":21.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":21.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":21.49,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":20.96,"methodology":"fee schedule"}]}]},{"description":"PROSTATECTOMY WITH CC ","code_information":[{"code":"666","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":29138.53,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":19739.00,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":12718.95,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":18799.05,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":18799.05,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":11609.02,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25731.90,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":18611.06,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":18611.06,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":18611.06,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":18611.06,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":18611.06,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":27258.62,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":19175.03,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":21929.17,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":18529.35,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":24164.42,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":18216.28,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":18216.28,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":24164.42,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":19926.99,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":18799.05,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":26130.68,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":23899.22,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":17470.20,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":18423.07,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":14557.95,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":19739.00,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":19175.03,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":19175.03,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":19175.03,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":19175.03,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":19175.03,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":20114.98,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":29138.53,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":29138.53,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":29138.53,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":19739.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":19739.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":19739.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":19739.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":19739.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":19739.00,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":18987.04,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":18423.07,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":18799.05,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":18347.87,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":18987.04,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":20678.96,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":18987.04,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":18987.04,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":18987.04,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":18987.04,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":18987.04,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":18611.06,"methodology":"fee 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HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":90.08,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":90.08,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":90.08,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":130.62,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":90.08,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":723.78,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":90.08,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":90.08,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":723.78,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":87.38,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":92.78,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":125.21,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":184.66,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":88.28,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":94.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":95.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":95.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":95.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":95.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":95.48,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":94.58,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":139.62,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":139.62,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":130.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":94.58,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":94.58,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":94.58,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":94.58,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":94.58,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":94.58,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":88.28,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":270.24,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":90.53,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":90.98,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":117.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":92.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":92.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":92.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":92.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":92.78,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":90.53,"methodology":"fee schedule"}]}]},{"description":"Prosthetic sock, single ply, fitting, upper limb, each ","code_information":[{"code":"L8485","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":12.65,"maximum":104.70,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":13.69,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":13.04,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":13.04,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":13.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":13.04,"methodology":"fee schedule"},{"payer_name":"Cigna 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schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":13.43,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":18.13,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":26.73,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":12.78,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":13.69,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":13.82,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":13.82,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":13.82,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":13.82,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":13.82,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13.69,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":20.21,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":20.21,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":18.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":13.69,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":13.69,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":13.69,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":13.69,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":13.69,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":13.69,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":12.78,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":39.12,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13.11,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":13.17,"methodology":"fee schedule"},{"payer_name":"Verda Health 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":12992.58,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":16942.79,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":16942.79,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":11477.50,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":22311.87,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":16773.36,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":16773.36,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":16773.36,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":16773.36,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":16773.36,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":24567.05,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16536.16,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":17112.22,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":18637.07,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":17112.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":17112.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":17112.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":17112.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":17112.22,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":16773.36,"methodology":"fee 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schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":9.91,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":8.05,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":9.25,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":28.32,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":9.49,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":9.53,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":12.27,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":9.72,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":9.72,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":9.72,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":9.72,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":9.72,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":9.49,"methodology":"fee schedule"}]}]},{"description":"Rabies vaccine, id ","code_information":[{"code":"9140","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":273.57,"maximum":837.45,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":293.11,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":279.15,"methodology":"fee 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schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":279.15,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":279.15,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":287.52,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":388.02,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":572.26,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":273.57,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":293.11,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":295.90,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":295.90,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":295.90,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":295.90,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":295.90,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":293.11,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":432.68,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":432.68,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":404.77,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":293.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":293.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":293.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":293.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":293.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":293.11,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":273.57,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":837.45,"methodology":"fee 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schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":218.58,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":294.97,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":435.03,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":207.97,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":222.82,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":224.94,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":224.94,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":224.94,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":224.94,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":224.94,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":222.82,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":328.93,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":328.93,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":307.70,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":222.82,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":222.82,"methodology":"fee schedule"},{"payer_name":"Superior Health 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Plan","plan_name":"MCR","standard_charge_dollar":275.87,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":218.58,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":218.58,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":218.58,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":218.58,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":218.58,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":213.27,"methodology":"fee schedule"}]}]},{"description":"Transplantation medicine, quantification of donor-derived cell-free DNA using whole genome next-generation sequencing, plasma, reported as percentage of donoe-derived cell-free DNA in the total cell-f ","code_information":[{"code":"0118U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2698.18,"maximum":16635.66,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":2890.91,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":13284.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":10141.20,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9784.80,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":2753.25,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":2753.25,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":11275.20,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10497.60,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":12895.25,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":13993.83,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16635.66,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":2753.25,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":2753.25,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":2753.25,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":2753.25,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":2753.25,"methodology":"fee schedule"},{"payer_name":"Community Health 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Plan","plan_name":"MCRSNP","standard_charge_dollar":2890.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":2890.91,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":2698.18,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":8259.75,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":2767.02,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":2780.78,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":3579.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":2835.85,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":2835.85,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":2835.85,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":2835.85,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":2835.85,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":2767.02,"methodology":"fee schedule"}]}]},{"description":"TRANSURETHRAL PROSTATECTOMY WITH CC/MCC ","code_information":[{"code":"713","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":26706.02,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":18091.17,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":10918.25,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":17229.69,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":17229.69,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":9965.46,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":22088.88,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":17057.39,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":17057.39,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":17057.39,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":17057.39,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":17057.39,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":24983.05,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":17574.28,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":19249.27,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":16264.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":21211.35,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":16695.57,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":16695.57,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":21211.35,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":18263.47,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":17229.69,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":23949.27,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":20978.56,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":15335.22,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":16885.10,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":12778.86,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":18091.17,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":17574.28,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":17574.28,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":17574.28,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":17574.28,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":17574.28,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":18435.77,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":26706.02,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":26706.02,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":26706.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":18091.17,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":18091.17,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":18091.17,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":18091.17,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":18091.17,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":18091.17,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":17401.99,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":16885.10,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":17229.69,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16816.18,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":17401.99,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":18952.66,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":17401.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":17401.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":17401.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":17401.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":17401.99,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":17057.39,"methodology":"fee schedule"}]}]},{"description":"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC ","code_information":[{"code":"604","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":27186.95,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":18416.97,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":12420.27,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":17539.97,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":17539.97,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":10971.93,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":21329.05,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":17364.57,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":17364.57,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":17364.57,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":17364.57,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":17364.57,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":25432.96,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":17890.77,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":19779.12,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":16712.64,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":21795.22,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":16996.23,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":16996.23,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":21795.22,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":18592.37,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":17539.97,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":24380.56,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":21556.02,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":15757.33,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":17189.17,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":13130.62,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":18416.97,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":17890.77,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":17890.77,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":17890.77,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":17890.77,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":17890.77,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":18767.77,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":27186.95,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":27186.95,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":27186.95,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":18416.97,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":18416.97,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":18416.97,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":18416.97,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":18416.97,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":18416.97,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":17715.37,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":17189.17,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":17539.97,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":27068.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":17119.01,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":18430.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":25619.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":18502.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":17715.37,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":19293.97,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":17715.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":17715.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":17715.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":17715.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":17715.37,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":17364.57,"methodology":"fee schedule"}]}]},{"description":"TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC ","code_information":[{"code":"082","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":37269.86,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":25247.32,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":19025.82,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":24045.07,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":24045.07,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":16807.19,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":32672.60,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":23804.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":23804.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":23804.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":23804.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":23804.62,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":34865.35,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":24525.97,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":30887.49,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":26098.80,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":34035.87,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":23299.67,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":23299.67,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":34035.87,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":25487.77,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":24045.07,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":33422.65,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":33662.33,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":24606.98,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":23564.17,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":20505.04,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":25247.32,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":24525.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":24525.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":24525.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":24525.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":24525.97,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":25728.22,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":37269.86,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":37269.86,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":37269.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":25247.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":25247.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":25247.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":25247.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":25247.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":25247.32,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":24285.52,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":23564.17,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":24045.07,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":37020.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":23467.99,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":26324.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":35040.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":25306.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":24285.52,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":26449.58,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":24285.52,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":24285.52,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":24285.52,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":24285.52,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":24285.52,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":23804.62,"methodology":"fee schedule"}]}]},{"description":"TRG@ (T cell antigen receptor, gamma) (eg, leukemia and lymphoma), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) ","code_information":[{"code":"81342","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":169.26,"maximum":1260.34,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":1260.34,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":1260.34,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":1260.34,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":992.35,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":992.35,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":992.35,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":920.37,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":920.37,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":920.37,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":1165.40,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":1165.40,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":1165.40,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":182.80,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":211.58,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":826.15,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":630.69,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":608.53,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":201.50,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":201.50,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":701.22,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":652.86,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":944.34,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":1024.79,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1218.26,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":201.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":201.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":201.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":201.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":201.50,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":292.18,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":169.26,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":169.26,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":169.26,"methodology":"fee schedule"},{"payer_name":"Community Health Choice 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":22032.92,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":22800.46,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":24832.18,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":22800.46,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":22800.46,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":22800.46,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":22800.46,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":22800.46,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":22348.96,"methodology":"fee 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","code_information":[{"code":"432445","type":"CDM"},{"code":"88285","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.60,"maximum":168.30,"gross_charge":1026.45,"discounted_cash":1026.45,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":168.30,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":168.30,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":168.30,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":132.52,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":132.52,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":132.52,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":122.90,"methodology":"fee 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schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":28.26,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":25.30,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":26.37,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":80.73,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":27.04,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":27.18,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":34.98,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":27.72,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":27.72,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":27.72,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":27.72,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":27.72,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":27.04,"methodology":"fee schedule"}]}]},{"description":"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC ","code_information":[{"code":"191","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":19615.13,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":13287.67,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":7431.66,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":12654.92,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":12654.92,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":6565.04,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12762.22,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":12528.37,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":12528.37,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":12528.37,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":12528.37,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":12528.37,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":18349.63,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":12908.02,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":11437.20,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9664.02,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12603.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":12262.62,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":12262.62,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12603.00,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":13414.22,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":12654.92,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":17590.34,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":12464.68,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":9111.61,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":12401.82,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":7592.73,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":13287.67,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":12908.02,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":12908.02,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":12908.02,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":12908.02,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":12908.02,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13540.76,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":19615.13,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":19615.13,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":19615.13,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":13287.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":13287.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":13287.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":13287.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":13287.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":13287.67,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":12781.47,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":12401.82,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":12654.92,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12351.20,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":12781.47,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":13920.41,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":12781.47,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":12781.47,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":12781.47,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":12781.47,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":12781.47,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":12528.37,"methodology":"fee schedule"}]}]},{"description":"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC ","code_information":[{"code":"433","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":22160.01,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":15011.62,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":8655.28,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":14296.78,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":14296.78,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":7645.98,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14863.52,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":14153.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":14153.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":14153.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":14153.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":14153.81,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":20730.33,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":14582.72,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":14240.92,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":12033.06,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":15692.50,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":13853.58,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":13853.58,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":15692.50,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":15154.59,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":14296.78,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":19872.52,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":15520.28,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":11345.24,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":14010.84,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":9454.01,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":15011.62,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":14582.72,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":14582.72,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":14582.72,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":14582.72,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":14582.72,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":15297.55,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":22160.01,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":22160.01,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":22160.01,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":15011.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":15011.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":15011.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":15011.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":15011.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":15011.62,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":14439.75,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":14010.84,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":14296.78,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13953.66,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":14439.75,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15726.46,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":14439.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":14439.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":14439.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":14439.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":14439.75,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":14153.81,"methodology":"fee schedule"}]}]},{"description":"Clot lysis time, whole blood dilution ","code_information":[{"code":"85175","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.11,"maximum":127.40,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":127.40,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":127.40,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":127.40,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":100.31,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":100.31,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":100.31,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":93.03,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":93.03,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":93.03,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":117.80,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":117.80,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":117.80,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":18.48,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":21.39,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":83.52,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":63.76,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":61.52,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":20.37,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":20.37,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":70.89,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":66.00,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":22.05,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":95.25,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":103.36,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":122.88,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":20.37,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":20.37,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":20.37,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":20.37,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":20.37,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":29.54,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":17.11,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":17.11,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":17.11,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":17.11,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":20.37,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":45.83,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":21.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":20.37,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":20.37,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":21.39,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":20.98,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":28.31,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":18.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":41.76,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":18.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":18.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":18.70,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":56.02,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":19.96,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":56.02,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":21.39,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":21.59,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":21.59,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":21.59,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":21.59,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":21.59,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":21.39,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":31.57,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":31.57,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":29.54,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":21.39,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":21.39,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":21.39,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":21.39,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":21.39,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":21.39,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":19.55,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":19.96,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":61.11,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":20.47,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":20.57,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":26.48,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":20.98,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":20.98,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":20.98,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":20.98,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":20.98,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":20.47,"methodology":"fee schedule"}]}]},{"description":"Clotting; factor II, prothrombin, specific ","code_information":[{"code":"101310","type":"CDM"},{"code":"85210","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.90,"maximum":81.15,"gross_charge":1738.30,"discounted_cash":1738.30,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":81.15,"methodology":"fee 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schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":75.03,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":75.03,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":11.77,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":13.63,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":53.22,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":40.63,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":39.20,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":12.98,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":12.98,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":45.17,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":42.06,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":14.05,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":60.29,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":65.43,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":77.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":12.98,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":12.98,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":12.98,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":12.98,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":12.98,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":18.82,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":10.90,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":10.90,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":10.90,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":10.90,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":12.98,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":36.07,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":12.50,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":12.98,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":12.98,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":13.63,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":13.37,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":18.04,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":11.00,"methodology":"fee schedule"},{"payer_name":"Molina 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schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":247.05,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":244.72,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":361.26,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":361.26,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":337.95,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":244.72,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":244.72,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":244.72,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":244.72,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":244.72,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":244.72,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":224.25,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":228.41,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":699.21,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":234.24,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":235.40,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":302.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":240.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":240.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":240.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":240.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":240.06,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":234.24,"methodology":"fee schedule"}]}]},{"description":"Complex rehabilitative power wheelchair accessory, power seat elevation system, any type ","code_information":[{"code":"E2298","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":195.35,"maximum":604.17,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":211.46,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":201.39,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":201.39,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":201.39,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":201.39,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":201.39,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":201.39,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":201.39,"methodology":"fee 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schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":211.46,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":312.15,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":312.15,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":292.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":211.46,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":211.46,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":211.46,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":211.46,"methodology":"fee schedule"},{"payer_name":"Superior Health 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schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":207.43,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":207.43,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":207.43,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":202.40,"methodology":"fee schedule"}]}]},{"description":"Composite dressing, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing ","code_information":[{"code":"A6204","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8.24,"maximum":68.28,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":8.91,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":9.18,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13.45,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12.36,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":8.49,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":8.49,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":16.77,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.53,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":8.49,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":8.49,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":8.49,"methodology":"fee schedule"},{"payer_name":"Cigna 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schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":8.24,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":8.74,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":11.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":17.40,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":8.32,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":8.91,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":9.00,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":9.00,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":9.00,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":9.00,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":9.00,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":8.91,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":13.16,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":13.16,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":12.31,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":8.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":8.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":8.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":8.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":8.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":8.91,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":8.32,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":25.47,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":8.53,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":8.57,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":11.04,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":8.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":8.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":8.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":8.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":8.74,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":8.53,"methodology":"fee schedule"}]}]},{"description":"CONCUSSION WITH CC ","code_information":[{"code":"089","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":22189.01,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":15031.26,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":8937.65,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":14315.49,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":14315.49,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":7895.42,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15348.43,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":14172.34,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":14172.34,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":14172.34,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":14172.34,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":14172.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":20757.46,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":14601.80,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":14272.87,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":12060.05,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":15727.71,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":13871.71,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":13871.71,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":15727.71,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":15174.42,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":14315.49,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":19898.53,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":15555.10,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":11370.69,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":14029.18,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":9475.22,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":15031.26,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. 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"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":86679.00,"methodology":"case rate","additional_payer_notes":"Days 0-15. "},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":86679.00,"methodology":"case rate","additional_payer_notes":"Days 0-15. "},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":68194.00,"methodology":"case rate","additional_payer_notes":"Days 0-15. "},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":68194.00,"methodology":"case rate","additional_payer_notes":"Days 0-15. "},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":68194.00,"methodology":"case rate","additional_payer_notes":"Days 0-15. "},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":63271.00,"methodology":"case rate","additional_payer_notes":"Days 0-15. 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"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":46293.53,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":45416.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 9. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":57920.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 9. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":41830.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 9. "},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":47906.22,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":52175.09,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":47906.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":47906.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":47906.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":47906.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":47906.22,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":46957.58,"methodology":"fee schedule"}]}]},{"description":"Corrugated tubing, disposable, used with large volume nebulizer, 100 feet 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Texas","plan_name":"POS","standard_charge_dollar":18.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":18.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":18.83,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":18.65,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":27.53,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":27.53,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":25.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":18.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":18.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":18.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":18.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":18.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":18.65,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":14.95,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":17.40,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":53.28,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":17.85,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":17.94,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":23.09,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":18.29,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":18.29,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":18.29,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":18.29,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":18.29,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":17.85,"methodology":"fee schedule"}]}]},{"description":"Darbepoetin alfa, 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HealthSpring","plan_name":"PFFS","standard_charge_dollar":3.04,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":4.40,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":3.04,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":3.04,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":3.04,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":3.13,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":4.22,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":6.22,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":2.98,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":3.19,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":3.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":3.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":3.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":3.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":3.22,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":3.19,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":4.71,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":4.71,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":4.40,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":3.19,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":3.19,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":3.19,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":3.19,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":3.19,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":3.19,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":2.98,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":9.11,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":3.05,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":3.07,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":3.95,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":3.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":3.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":3.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":3.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":3.13,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":3.05,"methodology":"fee schedule"}]}]},{"description":"DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC ","code_information":[{"code":"295","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":18777.71,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":12720.38,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":8270.38,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":12114.65,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":12114.65,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":7305.96,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14202.53,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":11993.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":11993.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":11993.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":11993.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":11993.50,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":17566.24,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":12356.94,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":10514.61,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":8884.46,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":11586.37,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":11739.10,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":11739.10,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":11586.37,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":12841.53,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":12114.65,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":16839.36,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":11459.21,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":8376.62,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":11872.36,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":6980.25,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":12720.38,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":12356.94,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":12356.94,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":12356.94,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":12356.94,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":12356.94,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":12962.68,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":18777.71,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":18777.71,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":18777.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":12720.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":12720.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":12720.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":12720.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":12720.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":12720.38,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":12235.80,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":11872.36,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":12114.65,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11823.90,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":12235.80,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":13326.11,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":12235.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":12235.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":12235.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":12235.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":12235.80,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":11993.50,"methodology":"fee schedule"}]}]},{"description":"DENTAL AND ORAL DISEASES WITH MCC ","code_information":[{"code":"157","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":29020.11,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":19658.78,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":13246.38,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":18722.65,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":18722.65,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":11701.71,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":22747.72,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":18535.42,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":18535.42,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":18535.42,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":18535.42,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":18535.42,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":27147.84,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":19097.10,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":21798.71,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":18419.11,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":24020.66,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":18142.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":18142.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":24020.66,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":19846.01,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":18722.65,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":26024.48,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":23757.04,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":17366.26,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":18348.20,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":14471.34,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":19658.78,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":18273.31,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":18909.88,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":20594.92,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":18909.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":18909.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":18909.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":18909.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":18909.88,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":18535.42,"methodology":"fee 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":10494.60,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":10860.19,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":11827.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":10860.19,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":10860.19,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":10860.19,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":10860.19,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":10860.19,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":10645.13,"methodology":"fee 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":23268.63,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":24079.22,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":26224.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":24079.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":24079.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":24079.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":24079.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":24079.22,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":23602.40,"methodology":"fee 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schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":36.09,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":34.82,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":11.53,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":11.53,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":40.12,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":37.36,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":12.48,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":53.98,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":58.58,"methodology":"fee 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schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":9226.23,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":4410.59,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":4725.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":4770.64,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":4770.64,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":4770.64,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":4770.64,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of 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Plan","plan_name":"MCRPPO","standard_charge_dollar":875.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":875.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":875.02,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":816.68,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":2500.05,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":837.52,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":841.68,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":1083.36,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":858.35,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":858.35,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":858.35,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":858.35,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":858.35,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":837.52,"methodology":"fee schedule"}]}]},{"description":"ENDOCRINE DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"645","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":18647.20,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":12631.97,"methodology":"fee 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":6459.31,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":12030.45,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":12030.45,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":5706.09,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11092.44,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":11910.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":11910.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":11910.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":11910.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":11910.15,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":17444.15,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":12271.06,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":10370.83,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":8762.97,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":11427.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":11657.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":11657.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":11427.93,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":12752.28,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":12030.45,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":16722.33,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":11302.51,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":8262.07,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":11789.84,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":6884.80,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":12631.97,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":12271.06,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":12271.06,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":12271.06,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":12271.06,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":12271.06,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":12872.58,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":18647.20,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":18647.20,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":18647.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":12631.97,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":12631.97,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":12631.97,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":12631.97,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":12631.97,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":12631.97,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":12150.75,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":11789.84,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":12030.45,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11741.72,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":1193.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":1339.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1215.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":20430.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":20430.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":1009.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1463.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":20225.70,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":20225.70,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":20225.70,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":20225.70,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":20225.70,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":29623.50,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":20838.60,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":24714.25,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":20882.64,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":27233.39,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":19796.67,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":19796.67,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":27233.39,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":21655.80,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":20430.00,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":28397.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":26934.51,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":19688.98,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":20021.40,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":16406.86,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":21451.50,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":20838.60,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":20838.60,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":20838.60,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":20838.60,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":20838.60,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":21860.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":21451.50,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":21451.50,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":21451.50,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":21451.50,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":21451.50,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":21451.50,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":20634.30,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":20430.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  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Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":32402.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":33050.04,"methodology":"fee schedule"}]}]},{"description":"Fine needle aspiration of orbital contents ","code_information":[{"code":"67415","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":782.10,"maximum":2422.24,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":782.10,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":782.10,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":782.10,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":782.10,"methodology":"fee 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subcutaneous port component only ","code_information":[{"code":"43887","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":794.09,"maximum":1890.30,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":794.09,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":794.09,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":794.09,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":794.09,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":931.25,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":1890.30,"methodology":"fee schedule"},{"payer_name":"Molina 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Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1086.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1086.80,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":1136.20,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":2632.64,"methodology":"fee schedule"}]}]},{"description":"Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C ","code_information":[{"code":"58558","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1191.14,"maximum":11899.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":6391.00,"methodology":"case rate"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":6391.00,"methodology":"case 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MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":1191.14,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":1191.14,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":1191.14,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":1397.50,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":3240.67,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1229.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1229.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1229.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1229.80,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":1285.70,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":2931.33,"methodology":"fee schedule"}]}]},{"description":"Incision of lingual frenum (frenotomy) ","code_information":[{"code":"41010","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":471.12,"maximum":1580.80,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":471.12,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":471.12,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":471.12,"methodology":"fee schedule"},{"payer_name":"Community Health Choice 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","code_information":[{"code":"36800","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2171.85,"maximum":10622.00,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2171.85,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2171.85,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2171.85,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2171.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":2548.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":5696.27,"methodology":"fee schedule"},{"payer_name":"Molina 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lead(s), single or dual chamber ","code_information":[{"code":"33249","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11612.00,"maximum":34101.98,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":24475.07,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":24475.07,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":24475.07,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":24475.07,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":11612.00,"methodology":"case rate"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":28736.25,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance 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","code_information":[{"code":"49320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2115.51,"maximum":6391.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":2483.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":5980.95,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2185.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":2185.70,"methodology":"fee schedule"},{"payer_name":"Molina 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Healthcare","plan_name":"STARPLUS","standard_charge_dollar":7246.80,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":7576.20,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":12340.12,"methodology":"fee schedule"}]}]},{"description":"LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR ","code_information":[{"code":"6942","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":6263.75,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":5813.80,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":5261.55,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":5261.55,"methodology":"fee schedule"},{"payer_name":"Community Health Choice 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reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":5011.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":5111.22,"methodology":"fee schedule"}]}]},{"description":"MAJOR BLADDER PROCEDURES ","code_information":[{"code":"4413","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":20838.75,"payers_information":[{"payer_name":"Aetna Better 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Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":16671.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":17004.42,"methodology":"fee schedule"}]}]},{"description":"Mechanical removal of intraluminal (intracatheter) obstructive material from central venous device through device lumen ","code_information":[{"code":"36596","type":"CPT"},{"code":"906989","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":499.82,"maximum":10622.00,"gross_charge":11075.42,"discounted_cash":11075.42,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":499.82,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":499.82,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":499.82,"methodology":"fee 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billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":22816.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":23272.32,"methodology":"fee schedule"}]}]},{"description":"NEONATE BIRTH WEIGHT < 500 GRAMS, OR BIRTH WEIGHT 500-999 GRAMS AND GESTATIONAL 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reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":14952.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":15251.04,"methodology":"fee schedule"}]}]},{"description":"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION ","code_information":[{"code":"6233","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":21117.50,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":19597.43,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":17738.70,"methodology":"fee schedule"},{"payer_name":"Community Health Choice 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Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":16894.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":17231.88,"methodology":"fee schedule"}]}]},{"description":"Open treatment of articular fracture, 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","code_information":[{"code":"23670","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2686.34,"maximum":7415.64,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":3153.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7415.64,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2775.30,"methodology":"fee 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MCD","plan_name":"STAR+PLUS","standard_charge_dollar":292.79,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":348.56,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":804.33,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":365.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":348.56,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":348.56,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":359.02,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":484.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":321.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":714.55,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":321.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":321.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":321.20,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":958.54,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":341.59,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":958.54,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":365.99,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":369.47,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":369.47,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":369.47,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":369.47,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":369.47,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":365.99,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":540.27,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":540.27,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":505.41,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":365.99,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":365.99,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":365.99,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":365.99,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":365.99,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":365.99,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":335.80,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":341.59,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":1045.68,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":350.30,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":352.05,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":453.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":359.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":359.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":359.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":359.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":359.02,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":350.30,"methodology":"fee schedule"}]}]},{"description":"MINOR SKIN DISORDERS WITHOUT MCC ","code_information":[{"code":"607","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":19677.96,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":13330.23,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":6960.19,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":12695.46,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":12695.46,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":6148.56,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11952.58,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":12568.51,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":12568.51,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":12568.51,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":12568.51,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":12568.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":18408.42,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":12949.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":12949.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":12949.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":12949.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":12949.37,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13584.14,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":19677.96,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":19677.96,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":19677.96,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":13330.23,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":13330.23,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":13330.23,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":13330.23,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":13330.23,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":13330.23,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":12822.41,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":12441.55,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":12695.46,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12390.77,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":12822.41,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":13965.01,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":12822.41,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":12822.41,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":12822.41,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":12822.41,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":12822.41,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":12568.51,"methodology":"fee 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schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":307.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":445.65,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":307.34,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":307.34,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":307.34,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":316.56,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":427.21,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":630.05,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":301.20,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":322.71,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":325.78,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":325.78,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":325.78,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":325.78,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":325.78,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":322.71,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":476.38,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":476.38,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":445.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":322.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":322.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":322.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":322.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":322.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":322.71,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":301.20,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":922.03,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":308.88,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":310.42,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":399.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":316.56,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":316.56,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":316.56,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":316.56,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":316.56,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":308.88,"methodology":"fee schedule"}]}]},{"description":"Mobility cart for pneumatic ventricular assist device, replacement only ","code_information":[{"code":"Q0502","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":747.45,"maximum":6190.94,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":809.10,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":770.57,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":770.57,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":770.57,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":770.57,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":770.57,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":770.57,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":770.57,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":770.57,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":1117.33,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":770.57,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":6190.94,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":770.57,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":770.57,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":6190.94,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":747.45,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":793.69,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":1071.09,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":1579.67,"methodology":"fee 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":37.90,"standard_charge_algorithm":"Reimbursement will be 37.9% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":37.20,"standard_charge_algorithm":"Reimbursement will be 37.2% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":23079.90,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":23079.90,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":32.00,"standard_charge_algorithm":"Reimbursement will be 32% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":43.50,"standard_charge_algorithm":"Reimbursement will be 43.5% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":17.40,"standard_charge_algorithm":"Reimbursement will be 17.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":18.90,"standard_charge_algorithm":"Reimbursement will be 18.9% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":22849.10,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":22849.10,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":22849.10,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":22849.10,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":22849.10,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":33465.86,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":23541.50,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_percentage":46.80,"standard_charge_algorithm":"Reimbursement will be 46.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":24706.18,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":32219.72,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":22364.42,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":22364.42,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":32219.72,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":24464.69,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":23079.90,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":32081.06,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":31866.12,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":27.70,"standard_charge_algorithm":"Reimbursement will be 27.7% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":22618.30,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":23.10,"standard_charge_algorithm":"Reimbursement will be 23.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":24233.90,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":23541.50,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":23541.50,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":23541.50,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":23541.50,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":23541.50,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":24695.49,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":35773.85,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":35773.85,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":35773.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":24233.90,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":24233.90,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":24233.90,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":24233.90,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":24233.90,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":24233.90,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":23310.70,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":22618.30,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":23079.90,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":22525.98,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":23310.70,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":25387.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":23310.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":23310.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":23310.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":23310.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":23310.70,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":22849.10,"methodology":"fee schedule"}]}]},{"description":"NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"601","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":16478.11,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":11162.59,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":5771.87,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":10631.04,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":10631.04,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":5098.80,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9911.90,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":10524.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":10524.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":10524.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":10524.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":10524.73,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":15415.01,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":10843.66,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":7981.14,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6743.78,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":8794.67,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":10301.48,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":10301.48,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":8794.67,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":11268.90,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":10631.04,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":14777.15,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":8698.15,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":6358.30,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":10418.42,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":5298.38,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":11162.59,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":10843.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":10843.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":10843.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":10843.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":10843.66,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":11375.21,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":16478.11,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":16478.11,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":16478.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":11162.59,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":11162.59,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":11162.59,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":11162.59,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":11162.59,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":11162.59,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":10737.35,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":10418.42,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":10631.04,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":10375.90,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":10737.35,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":11694.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":10737.35,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":10737.35,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":10737.35,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":10737.35,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":10737.35,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":10524.73,"methodology":"fee schedule"}]}]},{"description":"Non-segmental pneumatic appliance for use with pneumatic compressor, full arm ","code_information":[{"code":"E0665","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":181.32,"maximum":560.79,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":196.28,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":186.93,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":186.93,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":186.93,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":186.93,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":186.93,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":186.93,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":186.93,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":186.93,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":271.05,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":186.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":186.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":186.93,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":181.32,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":192.54,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":259.83,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":383.21,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":183.19,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":196.28,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":198.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":198.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":198.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":198.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":198.15,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":196.28,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":289.74,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":289.74,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":271.05,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":196.28,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":196.28,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":196.28,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":196.28,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":196.28,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":196.28,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":183.19,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":560.79,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":187.86,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":188.80,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":243.01,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":192.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":192.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":192.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":192.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":192.54,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":187.86,"methodology":"fee schedule"}]}]},{"description":"Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width ","code_information":[{"code":"E0371","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":235.33,"maximum":727.83,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":254.74,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":242.61,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":242.61,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":242.61,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":242.61,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":242.61,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":242.61,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":242.61,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":242.61,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":351.78,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":242.61,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":242.61,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":242.61,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":235.33,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":249.89,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":337.23,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":497.35,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":237.76,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":254.74,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":257.17,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":257.17,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":257.17,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":257.17,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":257.17,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":254.74,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":376.05,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":376.05,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":351.78,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":254.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":254.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":254.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":254.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":254.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":254.74,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":237.76,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":727.83,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":243.82,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":245.04,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":315.39,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":249.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":249.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":249.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":249.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":249.89,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":243.82,"methodology":"fee schedule"}]}]},{"description":"Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing ","code_information":[{"code":"E0434","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":43.25,"maximum":133.77,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":46.82,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":44.59,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":44.59,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":44.59,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":44.59,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":44.59,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":44.59,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":44.59,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":44.59,"methodology":"fee schedule"},{"payer_name":"Community Health 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schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":46.82,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":47.27,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":47.27,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":47.27,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":47.27,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":47.27,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":46.82,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":69.11,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":69.11,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":64.66,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":46.82,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":46.82,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":46.82,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":46.82,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":46.82,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":46.82,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":43.70,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":133.77,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":44.81,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":45.04,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":57.97,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":45.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":45.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":45.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":45.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":45.93,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":44.81,"methodology":"fee schedule"}]}]},{"description":"Positioning wheelchair back cushion, posterior, width 22 inches or greater, any height, including any type mounting hardware ","code_information":[{"code":"E2614","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":501.52,"maximum":1551.09,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":542.88,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":517.03,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":517.03,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":517.03,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":517.03,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":517.03,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":517.03,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":517.03,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":517.03,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":749.69,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":517.03,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":517.03,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":517.03,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":501.52,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":532.54,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":718.67,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":1059.91,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":506.69,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":542.88,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":548.05,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":548.05,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":548.05,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":548.05,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":548.05,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":542.88,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":801.40,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":801.40,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":749.69,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":542.88,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":542.88,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":542.88,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":542.88,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":542.88,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":542.88,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":506.69,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":1551.09,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":519.62,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":522.20,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":672.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":532.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":532.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":532.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":532.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":532.54,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":519.62,"methodology":"fee schedule"}]}]},{"description":"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC ","code_information":[{"code":"862","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":31451.41,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":21305.79,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":15939.87,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":20291.23,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":20291.23,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":14081.10,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":27373.17,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":20088.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":20088.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":20088.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":20088.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":20088.32,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":29422.28,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":20697.05,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":24477.28,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":20682.41,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":26972.26,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":19662.20,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":19662.20,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":26972.26,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":21508.70,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":20291.23,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":28204.81,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":26676.25,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":19500.19,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":19885.41,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":16249.55,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":21305.79,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":20697.05,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":20697.05,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":20697.05,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":20697.05,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":20697.05,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":21711.62,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":31451.41,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":31451.41,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":31451.41,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":21305.79,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":21305.79,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":21305.79,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":21305.79,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":21305.79,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":21305.79,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":20494.14,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":19885.41,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":20291.23,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":19804.24,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":20494.14,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":22320.35,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":20494.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":20494.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":20494.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":20494.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":20494.14,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":20088.32,"methodology":"fee schedule"}]}]},{"description":"Potassium; serum, plasma or whole blood ","code_information":[{"code":"103200","type":"CDM"},{"code":"84132","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.00,"maximum":29.79,"gross_charge":453.24,"discounted_cash":453.24,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":29.79,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":29.79,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":29.79,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":23.46,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":23.46,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":23.46,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":21.76,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":21.76,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":21.76,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":27.55,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":27.55,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":27.55,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":4.32,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":5.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":19.52,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":14.90,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.38,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":4.76,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":4.76,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":16.56,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15.42,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":5.15,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":22.23,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":24.13,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":4.76,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":4.76,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":4.76,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":4.76,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":4.76,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":6.90,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":4.00,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":4.00,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":4.00,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":4.00,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":4.76,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":12.78,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":5.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":4.76,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":4.76,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":5.00,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":4.90,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":6.62,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":4.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":9.76,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":4.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":4.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":4.40,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":13.09,"methodology":"fee 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schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":27.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":27.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":27.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":27.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":27.49,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":26.82,"methodology":"fee schedule"}]}]},{"description":"PROSTATECTOMY WITH MCC ","code_information":[{"code":"665","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":50722.97,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":34360.72,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":22237.87,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":32724.50,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":32724.50,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":20297.26,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":44989.78,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":32397.26,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":32397.26,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":32397.26,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":32397.26,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":32397.26,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":47450.53,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":31939.11,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":33051.75,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":35996.95,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":33051.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":33051.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":33051.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":33051.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":33051.75,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":32397.26,"methodology":"fee 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IPA","plan_name":"MCR","standard_charge_dollar":52.29,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":67.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":53.32,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":53.32,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":53.32,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":53.32,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":53.32,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":52.03,"methodology":"fee schedule"}]}]},{"description":"Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes ","code_information":[{"code":"97761","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":40.79,"maximum":388.14,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":44.15,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":51.84,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":139.23,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":139.65,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":42.05,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":42.05,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":43.90,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":138.39,"methodology":"fee 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":7461.07,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":12307.21,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":12307.21,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":6591.03,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12812.73,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":12184.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":12184.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":12184.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":12184.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":12184.14,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":17845.45,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12011.84,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":12430.28,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":13537.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":12430.28,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":12430.28,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":12430.28,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":12430.28,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":12430.28,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":12184.14,"methodology":"fee 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schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":85.16,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":85.16,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":107.83,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":107.83,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":107.83,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":16.91,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":19.57,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":76.42,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":58.34,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":56.29,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":18.64,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":18.64,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":64.87,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":60.39,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":20.17,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":87.31,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":94.75,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":112.64,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":18.64,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":18.64,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":18.64,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":18.64,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":18.64,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":27.03,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":15.66,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":15.66,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":15.66,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":15.66,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":18.64,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":41.94,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":18.75,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":18.64,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":18.64,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":19.56,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":19.20,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":25.91,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":16.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":38.21,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":16.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":16.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":16.50,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":51.26,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":18.27,"methodology":"fee 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schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":19.57,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":17.25,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":18.27,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":55.92,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":18.73,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":18.83,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":24.23,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":19.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":19.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":19.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":19.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":19.20,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":18.73,"methodology":"fee schedule"}]}]},{"description":"Rabies vaccine, im ","code_information":[{"code":"9139","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":343.14,"maximum":1050.42,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":367.65,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":350.14,"methodology":"fee 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schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":350.14,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":350.14,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":360.64,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":486.69,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":717.79,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":343.14,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":367.65,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":371.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":371.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":371.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":371.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":371.15,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":367.65,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":542.72,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":542.72,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":507.70,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":367.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":367.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":367.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":367.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":367.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":367.65,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":343.14,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":1050.42,"methodology":"fee 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Plan","plan_name":"MCRPPO","standard_charge_dollar":114.22,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":114.22,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":114.22,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":106.60,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":326.34,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":109.32,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":109.87,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":141.41,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":112.04,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":112.04,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":112.04,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":112.04,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":112.04,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":109.32,"methodology":"fee schedule"}]}]},{"description":"Transport chair, adult size, heavy duty, patient weight capacity greater than 300 pounds ","code_information":[{"code":"E1039","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":35.85,"maximum":110.88,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":38.81,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":36.96,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":36.96,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":36.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":36.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":36.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":36.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":36.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":36.96,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":53.59,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":36.96,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":36.96,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":36.96,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":35.85,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":38.07,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":51.37,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":75.77,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":36.22,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":38.81,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":39.18,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":39.18,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":39.18,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":39.18,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":39.18,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":38.81,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":57.29,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":57.29,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":53.59,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":38.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":38.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":38.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":38.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":38.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":38.81,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":36.22,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":110.88,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":37.14,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":37.33,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":48.05,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":38.07,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":38.07,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":38.07,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":38.07,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":38.07,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":37.14,"methodology":"fee schedule"}]}]},{"description":"TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC ","code_information":[{"code":"714","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":20587.89,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":13946.64,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":6790.46,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":13282.51,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":13282.51,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":6197.88,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13737.88,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13149.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13149.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":13149.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":13149.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":13149.68,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":19259.64,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":13548.16,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":12508.89,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":10569.56,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":13783.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":12870.75,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":12870.75,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":13783.93,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":14079.46,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":13282.51,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":18462.69,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":13632.66,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":9965.40,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":13016.86,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":8304.18,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":13946.64,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":13548.16,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":13548.16,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":13548.16,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":13548.16,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":13548.16,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":14212.29,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":20587.89,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":20587.89,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":20587.89,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":13946.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":13946.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":13946.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":13946.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":13946.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":13946.64,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":13415.34,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13016.86,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13282.51,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12963.73,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":13415.34,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":14610.76,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":13415.34,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":13415.34,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":13415.34,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":13415.34,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":13415.34,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13149.68,"methodology":"fee schedule"}]}]},{"description":"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC ","code_information":[{"code":"605","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":20395.75,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":13816.48,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":7596.38,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":13158.55,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":13158.55,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":6710.55,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13045.08,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13026.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13026.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":13026.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":13026.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":13026.96,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":19079.90,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":13421.72,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":12297.22,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":10390.70,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":13550.68,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":12750.63,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":12750.63,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":13550.68,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":13948.06,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":13158.55,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":18290.38,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":13401.96,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":9796.76,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":12895.38,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":8163.66,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":13816.48,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":13421.72,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":13421.72,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":13421.72,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":13421.72,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":13421.72,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":14079.65,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":20395.75,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":20395.75,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":20395.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":13816.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":13816.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":13816.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":13816.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":13816.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":13816.48,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":13290.14,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":12895.38,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13158.55,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":18489.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12842.74,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":12665.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":17499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":7610.66,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":13410.36,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":13410.36,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":6723.17,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13069.62,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13276.26,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13276.26,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":13276.26,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":13276.26,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":13276.26,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":19445.02,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":86.78,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":86.78,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":85.96,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":126.90,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":126.90,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":118.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":85.96,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":85.96,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":85.96,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":85.96,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":85.96,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":85.96,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":80.23,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":245.61,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":82.28,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":82.69,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":106.43,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":84.33,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":84.33,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":84.33,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":84.33,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":84.33,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":82.28,"methodology":"fee schedule"}]}]},{"description":"Troponin, qualitative ","code_information":[{"code":"84512","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.48,"maximum":63.12,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":63.12,"methodology":"fee 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Texas","plan_name":"POS","standard_charge_dollar":3962.36,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":3962.36,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":3962.36,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":3924.98,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":5794.02,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":5794.02,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":5420.22,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":3924.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":3924.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":3924.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":3924.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":3924.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":3924.98,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":3663.32,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":11214.24,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":3756.77,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":3775.46,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":4859.50,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":3850.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":3850.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":3850.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":3850.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":3850.22,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":3756.77,"methodology":"fee schedule"}]}]},{"description":"Upper extremity addition, suction socket ","code_information":[{"code":"L6686","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":736.84,"maximum":6103.08,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":797.61,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":759.63,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":759.63,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":759.63,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":759.63,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":759.63,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":759.63,"methodology":"fee schedule"},{"payer_name":"Cigna 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schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":805.21,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":805.21,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":797.61,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":1177.43,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":1177.43,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":1101.46,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":797.61,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":797.61,"methodology":"fee schedule"},{"payer_name":"Superior Health 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Plan","plan_name":"MCR","standard_charge_dollar":987.52,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":782.42,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":782.42,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":782.42,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":782.42,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":782.42,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":763.43,"methodology":"fee schedule"}]}]},{"description":"Upper extremity additions, single pivot hinge, pair ","code_information":[{"code":"L6605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":280.77,"maximum":2325.52,"payers_information":[{"payer_name":"American Health 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schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":306.82,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":303.92,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":448.65,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":448.65,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":419.70,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":303.92,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":303.92,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":303.92,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":303.92,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":303.92,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":303.92,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":283.66,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":868.35,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":290.90,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":292.34,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":376.29,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":298.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":298.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":298.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":298.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":298.13,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":290.90,"methodology":"fee schedule"}]}]},{"description":"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC ","code_information":[{"code":"256","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":29699.22,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":20118.83,"methodology":"fee 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":12020.75,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":19160.79,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":19160.79,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":10971.75,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":24319.36,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":18969.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":18969.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":18969.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":18969.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":18969.18,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":27783.15,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":19544.01,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":22546.90,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":19051.31,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":24845.11,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":18566.81,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":18566.81,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":24845.11,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":20310.44,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":19160.79,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":26633.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":24572.44,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":17962.32,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":18777.57,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":14968.04,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":20118.83,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":19544.01,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":19544.01,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":19544.01,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":19544.01,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":19544.01,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":20502.05,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":29699.22,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":29699.22,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":29699.22,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":20118.83,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":20118.83,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":20118.83,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":20118.83,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":20118.83,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":20118.83,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":19352.40,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":18777.57,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":19160.79,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":18700.93,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  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HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":5.75,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":5.75,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":5.75,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":5.75,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":5.75,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":8.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":4.83,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":4.83,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":4.83,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":4.83,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":5.75,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":13.97,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":5.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":5.75,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":5.75,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":6.03,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":5.92,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":7.99,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":4.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":11.79,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":4.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":4.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":4.40,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":15.81,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":5.63,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":15.81,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":6.04,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":6.10,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":6.10,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":6.10,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":6.10,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":6.10,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":6.04,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":8.91,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":8.91,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":8.34,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":6.04,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":6.04,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":6.04,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":6.04,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":6.04,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":6.04,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":4.60,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":5.63,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":17.25,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":5.78,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":5.81,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":7.48,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":5.92,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":5.92,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":5.92,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":5.92,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":5.92,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":5.78,"methodology":"fee schedule"}]}]},{"description":"CHOLECYSTECTOMY WITH C.D.E. WITH MCC ","code_information":[{"code":"411","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":55518.02,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":28655.13,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":27441.84,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":27290.60,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":27290.60,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":25047.11,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":55518.02,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":27017.69,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":27017.69,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":27017.69,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":27017.69,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":27017.69,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":39571.37,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":27836.41,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":36429.69,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":30781.76,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":40142.99,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":26444.59,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":26444.59,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":40142.99,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":28928.04,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":27290.60,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":37933.93,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":39702.43,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":29022.26,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":26744.79,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":24184.30,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":28655.13,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":27836.41,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":27836.41,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":27836.41,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":27836.41,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":27836.41,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":29200.94,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":42300.43,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":42300.43,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":42300.43,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":28655.13,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":28655.13,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":28655.13,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":28655.13,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":28655.13,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":28655.13,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":27563.51,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":26744.79,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":27290.60,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":26635.63,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":27563.51,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":30019.66,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":27563.51,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":27563.51,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":27563.51,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":27563.51,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":27563.51,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":27017.69,"methodology":"fee schedule"}]}]},{"description":"Chromium ","code_information":[{"code":"82495","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.04,"maximum":126.82,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":126.82,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":126.82,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":126.82,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":99.86,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":99.86,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":99.86,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":92.61,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":92.61,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":92.61,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":117.27,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":117.27,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":117.27,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":18.40,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":21.29,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":83.15,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":63.48,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":61.25,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":20.28,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":20.28,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":70.57,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":65.71,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":21.95,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":95.25,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":103.36,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":122.88,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":20.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":20.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":20.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":20.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":20.28,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":29.41,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":17.04,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":17.04,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":17.04,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":17.04,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":20.28,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":56.34,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":21.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":20.28,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":20.28,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":21.29,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":20.89,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":28.19,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":18.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":41.57,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":18.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":18.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":18.70,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":55.77,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":19.87,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":55.77,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":21.29,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":21.50,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":21.50,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":21.50,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":21.50,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":21.50,"methodology":"fee schedule"},{"payer_name":"Shared 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schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":21.29,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":19.55,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":19.87,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":60.84,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":20.38,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":20.48,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":26.36,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":20.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":20.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":20.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":20.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":20.89,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":20.38,"methodology":"fee schedule"}]}]},{"description":"Chromosome analysis; additional high resolution study ","code_information":[{"code":"88289","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":28.92,"maximum":215.38,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":215.38,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":215.38,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":215.38,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":169.58,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":169.58,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":169.58,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":157.28,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":157.28,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":157.28,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":199.15,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":199.15,"methodology":"fee 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Healthcare","plan_name":"STAR","standard_charge_dollar":30.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":30.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":30.80,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":94.68,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":33.74,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":94.68,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":36.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":36.50,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":36.50,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":36.50,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":36.50,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":36.50,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":36.15,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":53.37,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":53.37,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":49.92,"methodology":"fee schedule"},{"payer_name":"Superior Health 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Alliance","plan_name":"Veterans","standard_charge_dollar":103.29,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":34.60,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":34.77,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":44.76,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":35.46,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":35.46,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":35.46,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":35.46,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":35.46,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":34.60,"methodology":"fee schedule"}]}]},{"description":"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC ","code_information":[{"code":"190","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":22807.72,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":15450.39,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":9455.34,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":14714.66,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":14714.66,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":8352.74,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16237.44,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":14567.51,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":14567.51,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":14567.51,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":14567.51,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":14567.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":21336.26,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":15008.95,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":14954.49,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":12636.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":16478.81,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":14258.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":14258.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":16478.81,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":15597.54,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":14714.66,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":20453.38,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":16297.96,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":11913.72,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":14420.37,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":9927.73,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":15450.39,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":15008.95,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":15008.95,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":15008.95,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":15008.95,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":15008.95,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":15744.69,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":22807.72,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":22807.72,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":22807.72,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":15450.39,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":15450.39,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":15450.39,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":15450.39,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":15450.39,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":15450.39,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":14861.81,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":14420.37,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":14714.66,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":14361.51,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":14861.81,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":16186.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":14861.81,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":14861.81,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":14861.81,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":14861.81,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":14861.81,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":14567.51,"methodology":"fee schedule"}]}]},{"description":"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC ","code_information":[{"code":"432","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":32907.52,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":22292.19,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":15806.24,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":21230.66,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":21230.66,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":13963.06,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":27143.71,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":21018.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":21018.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":21018.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":21018.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":21018.35,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":30784.46,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":21655.27,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":26081.50,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":22037.92,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":28740.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":20572.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":20572.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":28740.00,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":22504.50,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":21230.66,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":29510.62,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":28424.58,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":20778.21,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":20806.05,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":17314.53,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":22292.19,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":21655.27,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":21655.27,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":21655.27,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":21655.27,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":21655.27,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":22716.81,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":32907.52,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":32907.52,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":32907.52,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":22292.19,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":22292.19,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":22292.19,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":22292.19,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":22292.19,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":22292.19,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":21442.97,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":20806.05,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":21230.66,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":20721.12,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":21442.97,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":23353.73,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":21442.97,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":21442.97,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":21442.97,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":21442.97,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":21442.97,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":21018.35,"methodology":"fee schedule"}]}]},{"description":"Clot retraction ","code_information":[{"code":"85170","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.69,"maximum":101.97,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":101.97,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":101.97,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":101.97,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":80.29,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":80.29,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":80.29,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":74.46,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":74.46,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":74.46,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":94.29,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":94.29,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":94.29,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":14.79,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":17.12,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":66.83,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":51.02,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":49.23,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":16.30,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":16.30,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":56.72,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":52.81,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":17.64,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":76.17,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":82.66,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":98.26,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":16.30,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":16.30,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":16.30,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":16.30,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":16.30,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":23.64,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":13.69,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":13.69,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":13.69,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":13.69,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":16.30,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":36.68,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":16.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":16.30,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":16.30,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":17.11,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":16.79,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":22.66,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":14.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":33.41,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":14.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":14.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":14.30,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":44.83,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":15.97,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":44.83,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":17.12,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":17.28,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":17.28,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":17.28,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":17.28,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":17.28,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":17.12,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":25.27,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":25.27,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":23.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":17.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":17.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":17.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":17.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":17.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":17.12,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":14.95,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":15.97,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":48.90,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16.38,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":16.46,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":21.19,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":16.79,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":16.79,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":16.79,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":16.79,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":16.79,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":16.38,"methodology":"fee schedule"}]}]},{"description":"Clotting; factor IX (PTC or Christmas) ","code_information":[{"code":"101320","type":"CDM"},{"code":"85250","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.99,"maximum":119.09,"gross_charge":1435.69,"discounted_cash":1435.69,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":119.09,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":119.09,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":119.09,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":93.77,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":93.77,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":93.77,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":86.96,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":86.96,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":86.96,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":110.12,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":110.12,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":110.12,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":17.27,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":19.99,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":78.06,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":59.60,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":57.50,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":19.04,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":19.04,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":66.26,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":61.69,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":20.61,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":88.89,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":96.46,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":114.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":19.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":19.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":19.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":19.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":19.04,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":27.61,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":15.99,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":15.99,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":15.99,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":15.99,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":19.04,"methodology":"fee 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":14101.28,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":14592.51,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15892.83,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":14592.51,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":14592.51,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":14592.51,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":14592.51,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":14592.51,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":14303.55,"methodology":"fee 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schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":33.05,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":31.89,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":10.56,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":10.56,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":36.75,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":34.21,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":11.43,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":49.20,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":53.39,"methodology":"fee 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MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":9.42,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":9.42,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":9.42,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":10.56,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":29.34,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":11.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":10.56,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":10.56,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":11.09,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":10.88,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":14.68,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":9.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":21.65,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":9.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":9.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":9.90,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":29.04,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":10.35,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":29.04,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":11.09,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":11.19,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":11.19,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":11.19,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":11.19,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":11.19,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":11.09,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":16.37,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":16.37,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":15.31,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":11.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":11.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":11.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":11.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":11.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":11.09,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":10.35,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":10.35,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":31.68,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":10.61,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":10.67,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":13.73,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":10.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":10.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":10.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":10.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":10.88,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":10.61,"methodology":"fee schedule"}]}]},{"description":"CONCUSSION WITH MCC ","code_information":[{"code":"088","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":26279.44,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":17802.20,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":12229.50,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":16954.48,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":16954.48,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":10803.40,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":21001.45,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":16784.94,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":16784.94,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":16784.94,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":16784.94,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":16784.94,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":24584.00,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":17293.57,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":18779.32,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":15867.84,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":20693.50,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":16428.89,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":16428.89,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":20693.50,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":17971.75,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":16954.48,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":23566.73,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":20466.40,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":14960.82,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":16615.39,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":12466.88,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":17802.20,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":17293.57,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":17293.57,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":17293.57,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":17293.57,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":17293.57,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":18141.29,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":26279.44,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":26279.44,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":26279.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":17802.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":17802.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":17802.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":17802.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":17802.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":17802.20,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":17124.02,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":16615.39,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":16954.48,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16547.57,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":17124.02,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":18649.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":17124.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":17124.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":17124.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":17124.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":17124.02,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":16784.94,"methodology":"fee schedule"}]}]},{"description":"Conforming bandage, non-elastic, knitted/woven, sterile, width less than three inches, per yard ","code_information":[{"code":"A6445","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.42,"maximum":3.51,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":0.45,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":0.47,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":0.69,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":0.63,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":0.43,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":0.43,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":0.86,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":0.74,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":0.43,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":0.43,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":0.43,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":0.43,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":0.43,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":0.43,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":0.62,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":0.43,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":3.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":0.43,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":0.43,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":3.51,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":0.42,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":0.44,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":0.60,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":0.88,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":0.42,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":0.45,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":0.46,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":0.46,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":0.46,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":0.46,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":0.46,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":0.45,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":0.67,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":0.67,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":0.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":0.45,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":0.45,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":0.45,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":0.45,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":0.45,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":0.45,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":0.42,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":1.29,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":0.43,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":0.43,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":0.56,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":0.44,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":0.44,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":0.44,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":0.44,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":0.44,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":0.43,"methodology":"fee schedule"}]}]},{"description":"Contact lens, gas permeable, extended wear, per lens ","code_information":[{"code":"V2513","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":239.75,"maximum":1985.79,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":259.52,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":247.16,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":247.16,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":247.16,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":247.16,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":247.16,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":247.16,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":247.16,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":247.16,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":358.38,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":247.16,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1985.79,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":247.16,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":247.16,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1985.79,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":239.75,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":254.57,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":343.55,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":506.68,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":242.22,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":259.52,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":261.99,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":261.99,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":261.99,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":261.99,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":261.99,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":259.52,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":383.10,"methodology":"fee 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"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":72737.18,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":79218.71,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":72737.18,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":72737.18,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":72737.18,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":72737.18,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":72737.18,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":71296.84,"methodology":"fee schedule"}]}]},{"description":"Corticosterone ","code_information":[{"code":"82528","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.92,"maximum":140.90,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":140.90,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":140.90,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":140.90,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":110.94,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":110.94,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":110.94,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":102.89,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":102.89,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":102.89,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":130.28,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":130.28,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":130.28,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":20.43,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":23.65,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":92.33,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":70.49,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":68.01,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":22.52,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":22.52,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":78.37,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":72.96,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":24.37,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":104.76,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":113.69,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":135.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":22.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":22.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":22.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":22.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":22.52,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":32.65,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":18.92,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":18.92,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":18.92,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":18.92,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":22.52,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":62.55,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":22.50,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":22.52,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":22.52,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":23.64,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":23.20,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":31.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":19.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":46.17,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":19.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":19.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":19.80,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":61.93,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":22.07,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":61.93,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":23.65,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":23.87,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":23.87,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":23.87,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":23.87,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":23.87,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":23.65,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":34.91,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":34.91,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":32.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":23.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":23.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":23.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":23.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":23.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":23.65,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":20.70,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":22.07,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":67.56,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":22.63,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":22.75,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":29.28,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":23.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":23.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":23.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":23.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":23.20,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":22.63,"methodology":"fee schedule"}]}]},{"description":"CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC ","code_information":[{"code":"073","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":27909.58,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":18906.49,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":12210.17,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":18006.18,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":18006.18,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":10786.33,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20968.25,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":17826.12,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":17826.12,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":17826.12,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":17826.12,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":17826.12,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":26108.96,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":18366.30,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":20575.24,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":17385.33,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":22672.49,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":17447.99,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":17447.99,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":22672.49,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":19086.55,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":18006.18,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":25028.59,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":22423.66,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":16391.57,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":17646.06,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":13659.13,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":18906.49,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":18366.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":18366.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":18366.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":18366.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":18366.30,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":19266.61,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":27909.58,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":27909.58,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":27909.58,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":18906.49,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":18906.49,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":18906.49,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":18906.49,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":18906.49,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":18906.49,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":18186.24,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":17646.06,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":18006.18,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":17574.03,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":18186.24,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":19806.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":18186.24,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":18186.24,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":18186.24,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":18186.24,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":18186.24,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":17826.12,"methodology":"fee schedule"}]}]},{"description":"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"027","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":58127.00,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":26454.75,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":18382.05,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":25195.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":25195.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":16777.92,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":37189.01,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":24943.05,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":24943.05,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":24943.05,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":24943.05,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":24943.05,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":36532.75,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":29.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":29.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":29.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":29.30,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":29.02,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":42.84,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":42.84,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":40.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":29.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":29.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":29.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":29.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":29.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":29.02,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":26.45,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":27.09,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":82.92,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":27.78,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":27.92,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":35.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":28.47,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":28.47,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":28.47,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":28.47,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":28.47,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":27.78,"methodology":"fee schedule"}]}]},{"description":"Darbepoetin alfa, non-esr ","code_information":[{"code":"1685","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":2.98,"maximum":9.11,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":3.19,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":3.04,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":3.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":3.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":3.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":3.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":3.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":3.04,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":4.40,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":3.04,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":3.04,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":3.04,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":3.13,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":4.22,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":6.22,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":2.98,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":3.19,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":3.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":3.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":3.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":3.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":3.22,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":3.19,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":4.71,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":4.71,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":4.40,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":3.19,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":3.19,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":3.19,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":3.19,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":3.19,"methodology":"fee schedule"},{"payer_name":"Superior Health 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schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":3.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":3.13,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":3.05,"methodology":"fee schedule"}]}]},{"description":"Degarelix injection ","code_information":[{"code":"1296","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":4.09,"maximum":12.53,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":4.38,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":4.18,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":4.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":4.18,"methodology":"fee schedule"},{"payer_name":"Cigna 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Texas","plan_name":"PPO","standard_charge_dollar":4.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":4.43,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":4.38,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":6.47,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":6.47,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":6.06,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":4.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":4.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":4.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":4.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":4.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":4.38,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":4.09,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":12.53,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":4.20,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":4.22,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":5.43,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":4.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":4.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":4.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":4.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":4.30,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":4.20,"methodology":"fee schedule"}]}]},{"description":"DENTAL AND ORAL DISEASES WITHOUT CC/MCC ","code_information":[{"code":"159","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":17204.36,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":11654.57,"methodology":"fee schedule","additional_payer_notes":"Days 1 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":5572.69,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":11099.59,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":11099.59,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":4922.85,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9569.86,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":10988.59,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":10988.59,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":10988.59,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":10988.59,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":10988.59,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":16094.41,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":11321.58,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":8781.25,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":7419.84,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":9676.33,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":10755.50,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":10755.50,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":9676.33,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":11765.57,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":11099.59,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":15428.43,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":9570.14,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":6995.72,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":10877.60,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":5829.54,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":11654.57,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":11321.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":11321.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":11321.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":11321.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":11321.58,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":11876.56,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":17204.36,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":17204.36,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":17204.36,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":11654.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":11654.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":11654.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":11654.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":11654.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":11654.57,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":11210.59,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":10877.60,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":11099.59,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":10833.20,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  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schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":60.11,"methodology":"fee schedule"}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITH CC ","code_information":[{"code":"445","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.00,"maximum":22337.65,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":15131.96,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":9055.31,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":14411.39,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":14411.39,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":7999.36,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15550.48,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":14267.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":14267.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":14267.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":14267.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":14267.28,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":20896.52,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":2663.00,"methodology":"per diem","additional_payer_notes":"Days 0 - 1. 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"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":14699.62,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":14699.62,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":14699.62,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":14699.62,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":14699.62,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":15420.19,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":22337.65,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":22337.65,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":22337.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":15131.96,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":15131.96,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":15131.96,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":15131.96,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":15131.96,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":15131.96,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":14555.50,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":14123.16,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":14411.39,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":14065.52,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":14555.50,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15852.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":14555.50,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":14555.50,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":14555.50,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":14555.50,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":14555.50,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":14267.28,"methodology":"fee 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HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":8.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":8.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":8.92,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":12.93,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":8.92,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":8.92,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":8.92,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":8.65,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":9.19,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":12.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":18.29,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":8.74,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":9.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":9.46,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":9.46,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":9.46,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":9.46,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":9.46,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":9.37,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":13.83,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":13.83,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":12.93,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":9.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":9.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":9.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":9.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":9.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":9.37,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":8.74,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":26.76,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":8.96,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":9.01,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":11.60,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":9.19,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":9.19,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":9.19,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":9.19,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":9.19,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":8.96,"methodology":"fee schedule"}]}]},{"description":"Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis (ie, CYP1A2, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, CYP4F2, SLCO1B1, VKORC1 and rs12777823) ","code_information":[{"code":"0029U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":727.42,"maximum":4642.79,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":4642.79,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":4642.79,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":4642.79,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":3655.56,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":3655.56,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":3655.56,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":3390.42,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":3390.42,"methodology":"fee 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schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":742.27,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":2583.10,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2404.95,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":3475.75,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3771.86,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4483.93,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":742.27,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":742.27,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":742.27,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":742.27,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":742.27,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":1076.29,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":742.27,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":742.27,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":742.27,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":764.54,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":1031.76,"methodology":"fee schedule"},{"payer_name":"Molina 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Plan","plan_name":"MCRPOS","standard_charge_dollar":779.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":779.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":779.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":779.38,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":727.42,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":2226.81,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":745.98,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":749.69,"methodology":"fee schedule"},{"payer_name":"Verda Health 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11906.83,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":12321.62,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":13419.58,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":12321.62,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":12321.62,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":12321.62,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":12321.62,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":12321.62,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":12077.62,"methodology":"fee 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schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":116.55,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":116.55,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":116.55,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":113.73,"methodology":"fee schedule"}]}]},{"description":"ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION ","code_information":[{"code":"880","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1009.00,"maximum":19474.41,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":14102.16,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":1193.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":1339.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1215.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":13430.63,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":13430.63,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":1009.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1463.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13296.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13296.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":13296.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":13296.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":13296.32,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":19474.41,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":13699.24,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":12761.84,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":10783.29,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":14062.66,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":13014.28,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":13014.28,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":14062.66,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":14236.47,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":13430.63,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":18668.58,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":13908.33,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":10166.91,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":13162.02,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":8472.11,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":14102.16,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":13699.24,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":13699.24,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":13699.24,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":13699.24,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":13699.24,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":14370.77,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":14102.16,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":14102.16,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":14102.16,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":14102.16,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":14102.16,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":14102.16,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":13564.94,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13430.63,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13108.29,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":13564.94,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":14773.69,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":13564.94,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":13564.94,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":13564.94,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":13564.94,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":13564.94,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13296.32,"methodology":"fee 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Plan","plan_name":"MCRPPO","standard_charge_dollar":23536.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":23536.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":23536.85,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":23536.85,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":47073.70,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":22971.97,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":23536.85,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":23536.85,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":23536.85,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":23536.85,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":23536.85,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":23301.48,"methodology":"fee schedule"}]}]},{"description":"AMPUTATION, LOWER EXTREMITY; M=39-45 ","code_information":[{"code":"D1004","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":34208.85,"maximum":70606.49,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":37068.41,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":35303.25,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":34950.21,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":34950.21,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":34950.21,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":34950.21,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":34950.21,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":34208.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":34208.85,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":37421.44,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":34597.18,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":35303.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":35303.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":35303.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":35303.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":35303.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":35303.25,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":35303.25,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":70606.49,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":34455.97,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":35303.25,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":35303.25,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":35303.25,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":35303.25,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":35303.25,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":34950.21,"methodology":"fee schedule"}]}]},{"description":"AMPUTATION, NON-LOWER EXTREMITY; M > 36.35 ","code_information":[{"code":"D1101","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":20010.92,"maximum":41302.20,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":21683.65,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":20651.10,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":20444.59,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":20444.59,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":20444.59,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":20444.59,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":20444.59,"methodology":"fee 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schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":20651.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":20651.10,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":20444.59,"methodology":"fee schedule"}]}]},{"description":"BURNS; M > 0 ","code_information":[{"code":"C2101","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":22502.19,"maximum":46444.16,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":24383.18,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":23222.08,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":22989.86,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":22989.86,"methodology":"fee 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Plan","plan_name":"MCRHMO","standard_charge_dollar":23222.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":23222.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":23222.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":23222.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":23222.08,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":23222.08,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":46444.16,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":22664.75,"methodology":"fee 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Plan","plan_name":"MCRHMO","standard_charge_dollar":24791.88,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":24791.88,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":24791.88,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":24791.88,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":24791.88,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":24791.88,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":49583.76,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":24196.87,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":24791.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":24791.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":24791.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":24791.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":24791.88,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":24543.96,"methodology":"fee schedule"}]}]},{"description":"OTHER ORTHOPEDIC; M > 44.75 ","code_information":[{"code":"A0901","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":16151.99,"maximum":33337.44,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":17502.16,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":16668.72,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":16502.03,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":16502.03,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":16502.03,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":16502.03,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":16502.03,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":16151.99,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":16151.99,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":17668.84,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":16335.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":16668.72,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":16668.72,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":16668.72,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":16668.72,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":16668.72,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":16668.72,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":16668.72,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":33337.44,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16268.67,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":16668.72,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":16668.72,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":16668.72,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":16668.72,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":16668.72,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":16502.03,"methodology":"fee schedule"}]}]},{"description":"PAIN SYNDROME; M > 26.75 & M < 37.15 ","code_information":[{"code":"A1602","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":18348.09,"maximum":37870.16,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":19881.84,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":18935.08,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":18745.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":18745.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":18745.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":18745.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":18745.73,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":18348.09,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":18348.09,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":20071.19,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":18556.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":18935.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":18935.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":18935.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":18935.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":18935.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":18935.08,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":18935.08,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":37870.16,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":18480.64,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":18935.08,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":18935.08,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":18935.08,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":18935.08,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":18935.08,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":18745.73,"methodology":"fee schedule"}]}]},{"description":"PSYCHOSES ","code_information":[{"code":"885","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1009.00,"maximum":24571.57,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":17793.21,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":1193.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":1339.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1215.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":16945.91,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":16945.91,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":1009.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1463.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":16776.45,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":16776.45,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":16776.45,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":16776.45,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":16776.45,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":24571.57,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":17284.83,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":18764.67,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":15855.47,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":20677.36,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":16420.59,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":16420.59,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":20677.36,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":17962.66,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":16945.91,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":23554.81,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":20450.44,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":14949.16,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":16606.99,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":12457.16,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":17793.21,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":17284.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":17284.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":17284.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":17284.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":17284.83,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":18132.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":17793.21,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":17793.21,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":17793.21,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":17793.21,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":17793.21,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":17793.21,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":17115.37,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":16945.91,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16539.21,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":17115.37,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":18640.50,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":17115.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":17115.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":17115.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":17115.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":17115.37,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":16776.45,"methodology":"fee 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HealthSpring","plan_name":"PFFS","standard_charge_dollar":28184.94,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":27587.08,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":27587.08,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":30177.82,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":27900.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":28469.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":28469.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":28469.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":28469.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":28469.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":28469.64,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":28469.64,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":56939.28,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":27786.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":28469.64,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":28469.64,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":28469.64,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":28469.64,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":28469.64,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":28184.94,"methodology":"fee schedule"}]}]},{"description":"PULMONARY; M > 49.25 ","code_information":[{"code":"D1501","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":19135.23,"maximum":39494.80,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":20734.77,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":19747.40,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":19549.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":19549.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":19549.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":19549.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":19549.92,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":19135.23,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":19135.23,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":20932.24,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":19352.45,"methodology":"fee schedule"},{"payer_name":"Superior Health 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schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":930.35,"methodology":"fee schedule"}]}]},{"description":"Hemorrhoidectomy, internal and external, single column/group; ","code_information":[{"code":"46255","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1052.72,"maximum":2910.45,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":1052.72,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":1052.72,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":1052.72,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":1052.72,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":1235.00,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":2910.45,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1086.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1086.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1086.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1086.80,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":1136.20,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":2632.64,"methodology":"fee schedule"}]}]},{"description":"Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, transvaginal or transrectal ","code_information":[{"code":"49407","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":544.82,"maximum":1680.57,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":544.82,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":544.82,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":544.82,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":544.82,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":638.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":1680.57,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":562.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":562.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":562.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":562.10,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":587.65,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":1520.15,"methodology":"fee schedule"}]}]},{"description":"Incision of thrombosed hemorrhoid, external ","code_information":[{"code":"46083","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":123.37,"maximum":256.18,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":123.37,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":123.37,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":123.37,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":123.37,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":143.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":256.18,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":126.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":126.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":126.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":126.50,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":132.25,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":231.73,"methodology":"fee schedule"}]}]},{"description":"Injection procedures (eg, thrombin) for percutaneous treatment of extremity pseudoaneurysm ","code_information":[{"code":"36002","type":"CPT"},{"code":"401223","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":250.60,"maximum":651.18,"gross_charge":2593.00,"discounted_cash":2593.00,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":250.60,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":250.60,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":250.60,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":250.60,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":293.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":651.18,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":258.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":258.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":258.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":258.50,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":270.25,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":589.02,"methodology":"fee schedule"}]}]},{"description":"Insertion of implantable intra-arterial infusion pump (eg, for chemotherapy of liver) ","code_information":[{"code":"36260","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2171.85,"maximum":5696.27,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2171.85,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2171.85,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2171.85,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2171.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":2548.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":5696.27,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2242.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":2242.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":2242.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":2242.90,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":2344.85,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":5152.54,"methodology":"fee schedule"}]}]},{"description":"INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE ","code_information":[{"code":"8174","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":11518.75,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":10690.29,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":9675.75,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":9675.75,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":9675.75,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":9675.75,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":11518.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":9675.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":9675.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":9675.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":9675.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":9215.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":9399.30,"methodology":"fee schedule"}]}]},{"description":"KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY ","code_information":[{"code":"4423","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":19382.50,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":17987.42,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":16281.30,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":16281.30,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":16281.30,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":16281.30,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":19382.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":16281.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":16281.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":16281.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":16281.30,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":15506.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":15816.12,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; ","code_information":[{"code":"58570","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3483.21,"maximum":17479.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":3483.21,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":3483.21,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":3483.21,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":3483.21,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":17479.00,"methodology":"case rate"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":8321.00,"methodology":"case rate"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":4088.75,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":8321.00,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":10670.08,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":3598.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":3598.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":3598.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":3598.10,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":14838.00,"methodology":"case rate"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":12365.00,"methodology":"case rate"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":3761.65,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":9651.57,"methodology":"fee schedule"}]}]},{"description":"Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions ","code_information":[{"code":"37700","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1252.41,"maximum":3304.03,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":1252.41,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":1252.41,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":1252.41,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":1252.41,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":1470.00,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":3304.03,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1293.60,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1293.60,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1293.60,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1293.60,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":1352.40,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":2988.65,"methodology":"fee schedule"}]}]},{"description":"LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA ","code_information":[{"code":"6911","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":8463.75,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":7854.91,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":7109.55,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":7109.55,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":7109.55,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":7109.55,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":8463.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":7109.55,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":7109.55,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":7109.55,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":7109.55,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":6771.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":6906.42,"methodology":"fee schedule"}]}]},{"description":"MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS ","code_information":[{"code":"2484","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":25212.50,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":23397.69,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":21178.50,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":21178.50,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":21178.50,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":21178.50,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":25212.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":21178.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":21178.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":21178.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":21178.50,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":20170.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":20573.40,"methodology":"fee schedule"}]}]},{"description":"Methylphenidate 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for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":11899.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":3153.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7415.64,"methodology":"fee 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reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":5112.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":5214.24,"methodology":"fee schedule"}]}]},{"description":"Monitoring of interstitial fluid pressure (includes insertion of device, eg, wick catheter technique, needle manometer technique) in detection of muscle compartment syndrome ","code_information":[{"code":"20950","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":288.51,"maximum":729.30,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":288.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":288.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":288.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":288.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":338.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":729.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":298.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":298.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":298.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":298.10,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":311.65,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":659.68,"methodology":"fee schedule"}]}]},{"description":"Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia ","code_information":[{"code":"31298","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1825.73,"maximum":7094.55,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":1825.73,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":1825.73,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":1825.73,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":1825.73,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":2142.50,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7094.55,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1885.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1885.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1885.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1885.40,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":1971.10,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6417.34,"methodology":"fee schedule"}]}]},{"description":"NEONATE BIRTH WEIGHT > 2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM ","code_information":[{"code":"6404","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":26633.75,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":24716.55,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":22372.35,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":22372.35,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":22372.35,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":22372.35,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":26633.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":22372.35,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":22372.35,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":22372.35,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":22372.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":21307.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":21733.14,"methodology":"fee schedule"}]}]},{"description":"NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION ","code_information":[{"code":"0464","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":13160.00,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":12212.96,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":11054.40,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":11054.40,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":11054.40,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":11054.40,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":13160.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":11054.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":11054.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":11054.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":11054.40,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":10528.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":10738.56,"methodology":"fee schedule"}]}]},{"description":"Open treatment of proximal tibiofibular joint dislocation, includes internal fixation, when performed, or with excision of proximal fibula ","code_information":[{"code":"27832","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3714.88,"maximum":7415.64,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":3714.88,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":3714.88,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":3714.88,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":3714.88,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":4361.25,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7415.64,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":3837.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":3837.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":3837.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":3837.90,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":4012.35,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6707.78,"methodology":"fee schedule"}]}]},{"description":"Ophthalmic ultrasound, diagnostic; B-scan (with or without superimposed non-quantitative A-scan) ","code_information":[{"code":"76512","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":47.78,"maximum":427.02,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":176.54,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":176.54,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":176.54,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":138.90,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":138.90,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":138.90,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":128.83,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":128.83,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":128.83,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":163.41,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":163.41,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":163.41,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":51.60,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":186.05,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":378.83,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":330.64,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":159.15,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":427.02,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":47.78,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":47.78,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":47.78,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":47.78,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":197.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":58.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":51.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":51.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":51.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":51.70,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":54.05,"methodology":"fee schedule"}]}]},{"description":"Orthopantogram (eg, panoramic x-ray) ","code_information":[{"code":"70355","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.04,"maximum":304.08,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":81.31,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":81.31,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":81.31,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":63.97,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":63.97,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":63.97,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":59.34,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":59.34,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":59.34,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":75.26,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":75.26,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":75.26,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":19.48,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":132.48,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":269.76,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":235.44,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":113.33,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":304.08,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":23.62,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":25.62,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":30.40,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":18.04,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":18.04,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":18.04,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":18.04,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":22.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":19.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":19.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":19.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":19.80,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":20.70,"methodology":"fee schedule"}]}]},{"description":"OTHER CARDIOTHORACIC AND THORACIC CIRCULATORY PROCEDURES ","code_information":[{"code":"1672","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":18799.14,"maximum":26873.75,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":24939.76,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":22573.95,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":22573.95,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":22573.95,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":22573.95,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":26873.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":22573.95,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":22573.95,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":22573.95,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":22573.95,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":18799.14,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":18799.14,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":18799.14,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":18799.14,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":18799.14,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":21499.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":21928.98,"methodology":"fee schedule"}]}]},{"description":"OTHER MENTAL HEALTH CONDITIONS AND DISORDERS ","code_information":[{"code":"7604","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":13645.00,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":12662.96,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":11461.80,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":11461.80,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":11461.80,"methodology":"fee schedule"},{"payer_name":"Community 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of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or 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days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":24835.54,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":24835.54,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":28403.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":28971.06,"methodology":"fee schedule"}]}]},{"description":"Perineoplasty, repair of perineum, 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days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":15086.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":15387.72,"methodology":"fee schedule"}]}]},{"description":"Vestibular nerve section, translabyrinthine approach ","code_information":[{"code":"69915","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":993.01,"maximum":3337.33,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":993.01,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":993.01,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":993.01,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":993.01,"methodology":"fee 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reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross 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charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":3446.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":3514.92,"methodology":"fee schedule"}]}]},{"description":"APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS ","code_information":[{"code":"2344","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":23535.00,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":21841.32,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":19769.40,"methodology":"fee schedule"},{"payer_name":"Community Health Choice 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days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":18828.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":19204.56,"methodology":"fee schedule"}]}]},{"description":"Arteriovenous anastomosis, open; by upper arm basilic vein transposition ","code_information":[{"code":"36819","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2171.85,"maximum":10622.00,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2171.85,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2171.85,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2171.85,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2171.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":2548.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":5696.27,"methodology":"fee schedule"},{"payer_name":"Molina 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","code_information":[{"code":"21243","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10896.28,"maximum":19317.45,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":10896.28,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":10896.28,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":10896.28,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":10896.28,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":12792.50,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":19317.45,"methodology":"fee schedule"},{"payer_name":"Molina 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necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":6918.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":7056.36,"methodology":"fee schedule"}]}]},{"description":"Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study ","code_information":[{"code":"93925","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":230.13,"maximum":2077.05,"payers_information":[{"payer_name":"Aetna Better 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medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":93686.93,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":93686.93,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":93686.93,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":93686.93,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":107145.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":109287.90,"methodology":"fee schedule"}]}]},{"description":"Incision and drainage, perianal abscess, superficial ","code_information":[{"code":"46050","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":367.92,"maximum":947.37,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":367.92,"methodology":"fee 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Healthcare","plan_name":"STARPLUS","standard_charge_dollar":7697.55,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":7331.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":7477.62,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; with fimbrioplasty ","code_information":[{"code":"58672","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2115.51,"maximum":11899.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":9237.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":10005.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":11899.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":2483.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":5980.95,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2185.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":2185.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":2185.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":2185.70,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":2285.05,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":5410.04,"methodology":"fee schedule"}]}]},{"description":"Lengthening of tendon, extensor, hand or finger, each tendon ","code_information":[{"code":"26476","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1218.86,"maximum":3355.18,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":1430.00,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":3355.18,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":1315.60,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":3034.92,"methodology":"fee schedule"}]}]},{"description":"OTHER EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL DIAGNOSES ","code_information":[{"code":"1152","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":5792.50,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":5376.05,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":4865.70,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":4865.70,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":4865.70,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":4865.70,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":5792.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":4865.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":4865.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":4865.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":4865.70,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":4634.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":4726.68,"methodology":"fee schedule"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES ","code_information":[{"code":"3514","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":26525.00,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":24615.92,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":22281.00,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":22281.00,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":22281.00,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":22281.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":26525.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":22281.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":22281.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":22281.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":22281.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":21220.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":21644.40,"methodology":"fee schedule"}]}]},{"description":"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES ","code_information":[{"code":"1433","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":7776.25,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":7216.93,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":6532.05,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":6532.05,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":6532.05,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":6532.05,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":7776.25,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":6532.05,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":6532.05,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":6532.05,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":6532.05,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":6221.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":6345.42,"methodology":"fee schedule"}]}]},{"description":"PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT ","code_information":[{"code":"8441","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":3195.00,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":2965.64,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2683.80,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2683.80,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2683.80,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2683.80,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":3195.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2683.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":2683.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":2683.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":2683.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":2556.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2607.12,"methodology":"fee schedule"}]}]},{"description":"Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administe ","code_information":[{"code":"62263","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":381.66,"maximum":944.81,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":381.66,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":381.66,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":381.66,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":381.66,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":447.50,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":944.81,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":393.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":393.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":393.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":393.80,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":411.70,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":854.62,"methodology":"fee schedule"}]}]},{"description":"Peritoneal lavage, including imaging guidance, when performed ","code_information":[{"code":"49084","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":375.14,"maximum":939.63,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":375.14,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":375.14,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":375.14,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":375.14,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":440.00,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":939.63,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":387.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":387.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":387.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":387.20,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":404.80,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":849.94,"methodology":"fee schedule"}]}]},{"description":"Plastic repair of cleft lip/nasal deformity; primary bilateral, 1-stage procedure ","code_information":[{"code":"40701","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2188.73,"maximum":6070.29,"payers_information":[{"payer_name":"Community Health Choice 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reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 12% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":4331.00,"methodology":"fee 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