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"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":19783.31,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":31911.26,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":26963.85,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":35163.99,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":18794.14,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":18794.14,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":35163.99,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":23780.64,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":20559.12,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":19395.40,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":26959.61,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":32965.94,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":21800.71,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":29122.19,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":25422.58,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":19007.49,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":21184.69,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":20365.17,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":19783.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":19783.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":19783.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":19783.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":19783.31,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":20753.08,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":30062.87,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":30062.87,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":30062.87,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":20365.17,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":20365.17,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":20365.17,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":20365.17,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":20365.17,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":20365.17,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":19395.40,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":19589.35,"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":18929.91,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":19395.40,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":30062.87,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":19589.35,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":21334.94,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":19977.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":19977.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":19977.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":19977.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":19977.26,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":19201.45,"methodology":"fee schedule"}]}]},{"description":"Bilirubin; total ","code_information":[{"code":"302250","type":"CDM"},{"code":"82247","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3.92,"maximum":31.44,"gross_charge":943.35,"discounted_cash":943.35,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":31.44,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":31.44,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":31.44,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":24.75,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":24.75,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":24.75,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":5.06,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":22.96,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":22.96,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":22.96,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":29.07,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":29.07,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":29.07,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":4.56,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":5.27,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":5.02,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":4.22,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MCDCHIPBH","standard_charge_dollar":4.22,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":4.87,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":16.92,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":16.97,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":4.17,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16.82,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":5.43,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":23.81,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":25.84,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":30.72,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":5.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":5.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":5.02,"methodology":"fee 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schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":7.78,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":7.28,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":5.27,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":5.27,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":5.27,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":5.27,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":5.27,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":5.27,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"STAR","standard_charge_dollar":4.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"STARKIDS","standard_charge_dollar":4.00,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":3.92,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":5.05,"methodology":"fee schedule"},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":6.02,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":7.78,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":5.07,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":6.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":5.17,"methodology":"fee 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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":17602.69,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":10202.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":12002.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9670.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":18035.54,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":27955.09,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":18215.90,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":19839.09,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":18576.61,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":18576.61,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":18576.61,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":18576.61,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":18576.61,"methodology":"fee 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"},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":16583.82,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":22746.58,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":19338.98,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":14846.26,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":16115.21,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":15906.70,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":15452.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":15452.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":15452.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":15452.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":15452.22,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":16209.69,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":23481.32,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":23481.32,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":23481.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":15906.70,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":15906.70,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":15906.70,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":15906.70,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":15906.70,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":15906.70,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":15149.24,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":15300.73,"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":14785.66,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":15149.24,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":23481.32,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":15300.73,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":16664.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":15603.72,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":15603.72,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":15603.72,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":15603.72,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":15603.72,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":14997.75,"methodology":"fee schedule"}]}]},{"description":"Crutch, underarm, articulating, spring assisted, each ","code_information":[{"code":"E0117","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":25.49,"maximum":55.19,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":26.50,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":27.59,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":26.28,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":26.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":26.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":26.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":26.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":26.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":26.28,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":38.11,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":52.03,"methodology":"fee schedule"},{"payer_name":"Devoted 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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":8238.38,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":6428.53,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":6586.60,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":10209.24,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":6652.47,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":7245.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":6784.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":6784.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":6784.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":6784.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":6784.20,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6520.74,"methodology":"fee schedule"}]}]},{"description":"Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay ºEIA», enzyme-linked immunosorbent assay ºELISA», fluorescence immunoassay ºFIA», immunochemiluminometric assay ºIMC ","code_information":[{"code":"87336","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.74,"maximum":100.08,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":100.08,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":100.08,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":100.08,"methodology":"fee 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If billable gross charges exceed threshold of $492951.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10152 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":8824.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7.  If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 21.8% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":6708.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7.  If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12973.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7.  If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":7516.70,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":7516.70,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":7516.70,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":7516.70,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":7516.70,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":11009.30,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":10748.88,"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":7744.48,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":3087.00,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9028.45,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":11774.14,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":7357.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":7357.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":11774.14,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":7962.59,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":8048.18,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":7592.62,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":10553.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":11038.16,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":7299.65,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":11400.32,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":8512.38,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":7440.77,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":7093.38,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":7972.26,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":7744.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":7744.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":7744.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":7744.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":7744.48,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":8124.11,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":11768.57,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":11768.57,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":11768.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":7972.26,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":7972.26,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":7972.26,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":7972.26,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":7972.26,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":7972.26,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":7592.62,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":7668.55,"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":7410.40,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":7592.62,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":11768.57,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":7668.55,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":8351.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":7820.40,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":7820.40,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":7820.40,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":7820.40,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":7820.40,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":7516.70,"methodology":"fee schedule"}]}]},{"description":"Leg strap; foam or fabric, replacement only, per set ","code_information":[{"code":"A5114","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":11.84,"maximum":98.18,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":12.31,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":12.82,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":12.21,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":13.21,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":19.34,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":17.78,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":21.22,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20.90,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":12.21,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":12.21,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":12.21,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":12.21,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":12.21,"methodology":"fee schedule"},{"payer_name":"Cigna 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schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":12.58,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":16.97,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":25.03,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":25.64,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":11.97,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":12.82,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":12.94,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":12.94,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health 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","code_information":[{"code":"5591","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":380.88,"maximum":816.18,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":391.96,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":408.09,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":388.66,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":388.66,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":388.66,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":388.66,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":388.66,"methodology":"fee schedule"},{"payer_name":"Cigna 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Healthcare","plan_name":"HIX","standard_charge_dollar":796.74,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":816.18,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":380.88,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":408.09,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":411.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":411.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":411.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":411.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":411.97,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":408.09,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":602.42,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":602.42,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":563.55,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":408.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":408.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":408.09,"methodology":"fee schedule"},{"payer_name":"Superior Health 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"},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":7956.31,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":12202.83,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":9278.13,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":7964.55,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":7731.48,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":8533.45,"methodology":"fee schedule","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":7932.04,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":8127.09,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":12597.00,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":8208.36,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":8939.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":8370.91,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":8370.91,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":8370.91,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":8370.91,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":8370.91,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":8045.82,"methodology":"fee schedule"}]}]},{"description":"Ostomy pouch, drainable; for use on barrier with flange (2 piece system), each ","code_information":[{"code":"A5063","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3.58,"maximum":29.61,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":3.72,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":3.87,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":3.69,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":3.99,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":5.84,"methodology":"fee 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IPA","plan_name":"MCR","standard_charge_dollar":3.80,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":5.13,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":7.56,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":7.75,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":3.62,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":3.87,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":3.91,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":3.91,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":3.91,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":3.91,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":3.91,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":3.87,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":5.72,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":5.72,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":5.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":3.87,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":3.87,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":3.87,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":3.87,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":3.87,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":3.87,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":3.71,"methodology":"fee schedule"},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":4.43,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":5.72,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":3.73,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":4.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":3.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":3.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":3.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":3.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":3.80,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":3.71,"methodology":"fee schedule"}]}]},{"description":"OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC ","code_information":[{"code":"394","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":13808.87,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":8507.32,"methodology":"fee schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":9050.34,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":8619.37,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":8471.70,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":8392.83,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":7390.77,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12764.25,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":8533.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":8533.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":8533.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":8533.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":8533.18,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":12498.09,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":12202.44,"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":8791.76,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":12531.53,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":10588.68,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":13808.87,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":8352.17,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":8352.17,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":13808.87,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":9338.64,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":9136.53,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":8619.37,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":11980.92,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":12945.70,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":8561.12,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":12941.98,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":9983.43,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":8446.98,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":8319.21,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":9050.34,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":8791.76,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":8791.76,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":8791.76,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":8791.76,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":8791.76,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":9222.73,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":13360.02,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":13360.02,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":13360.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":9050.34,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":9050.34,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":9050.34,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":9050.34,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":9050.34,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":9050.34,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":8619.37,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":8705.56,"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":8412.51,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":8619.37,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":13360.02,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":8705.56,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":9481.31,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":8877.95,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":8877.95,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":8877.95,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":8877.95,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":8877.95,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":8533.18,"methodology":"fee schedule"}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"718","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":18070.51,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":10629.83,"methodology":"fee schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":11308.33,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":10769.84,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":11086.20,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":10459.53,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":9429.87,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15728.80,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":10662.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":10662.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":10662.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":10662.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":10662.14,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":15616.27,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":15246.86,"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":10985.24,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":16398.95,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":13856.52,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":18070.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":10435.97,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":10435.97,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":18070.51,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":12220.69,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":11416.03,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":10769.84,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":14970.08,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":16940.95,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","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":10511.36,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":10769.84,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":16693.25,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":10877.54,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":11846.82,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":11092.94,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":11092.94,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":11092.94,"methodology":"fee 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schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":21.92,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":8.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":8.45,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":8.45,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":8.45,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":8.45,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":8.45,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":8.37,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":12.35,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":12.35,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":11.56,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":8.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":8.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":8.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":8.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":8.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":8.37,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"STAR","standard_charge_dollar":6.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"STARKIDS","standard_charge_dollar":6.00,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":5.88,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":8.01,"methodology":"fee schedule"},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":9.56,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":12.35,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":8.05,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":10.36,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":8.21,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":8.21,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":8.21,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":8.21,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":8.21,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":8.01,"methodology":"fee schedule"}]}]},{"description":"AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC ","code_information":[{"code":"240","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":42719.04,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":22906.06,"methodology":"fee schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":24368.15,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":23207.76,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":26208.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":23626.71,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":21300.85,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":35529.31,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":22975.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":22975.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":22975.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":22975.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":22975.68,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":33651.25,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":32855.23,"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":23671.92,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":38767.46,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":32757.09,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":42719.04,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":22488.32,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":22488.32,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":42719.04,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":28889.95,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":24600.23,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":23207.76,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":32258.79,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":40048.74,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":26484.64,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":34846.45,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":30884.67,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":22743.60,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":25736.26,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":24368.15,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":23671.92,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":23671.92,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":23671.92,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":23671.92,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":23671.92,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":24832.30,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":35972.03,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":35972.03,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":35972.03,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":24368.15,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":24368.15,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":24368.15,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":24368.15,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":24368.15,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":24368.15,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":23207.76,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":23439.84,"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":22650.77,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":23207.76,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":35972.03,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":23439.84,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":25528.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":23903.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":23903.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":23903.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":23903.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":23903.99,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":22975.68,"methodology":"fee schedule"}]}]},{"description":"Antibody; Chlamydia, IgM ","code_information":[{"code":"319012","type":"CDM"},{"code":"86632","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.80,"maximum":79.34,"gross_charge":561.97,"discounted_cash":561.97,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":79.34,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":79.34,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":79.34,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":62.47,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":62.47,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":62.47,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":12.79,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":57.94,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":57.94,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":57.94,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":73.36,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":73.36,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":73.36,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":11.50,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":13.31,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":12.68,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":10.65,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MCDCHIPBH","standard_charge_dollar":10.65,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":12.30,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":42.73,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":42.86,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":10.52,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":42.48,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":13.72,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":58.72,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":63.72,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":75.75,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":12.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":12.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":12.68,"methodology":"fee 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schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":474346.31,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":474346.31,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":474346.31,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":462833.05,"methodology":"fee schedule"}]}]},{"description":"CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC ","code_information":[{"code":"259","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":38974.03,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed 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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":14310.26,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":14486.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":18474.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":13342.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":14662.15,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":22726.33,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":14808.77,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":16128.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":15102.01,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":15102.01,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":15102.01,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":15102.01,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":15102.01,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":14515.53,"methodology":"fee schedule"}]}]},{"description":"Cast supplies, short leg cast, pediatric (0-10 years), fiberglass ","code_information":[{"code":"Q4040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":24.37,"maximum":201.81,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":25.33,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":26.38,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":25.12,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":27.17,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":39.79,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":36.58,"methodology":"fee 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"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":22837.63,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":25758.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":11002.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $492951.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10152 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9264.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 21.8% of billable gross charges, or (b) $9240 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":22609.25,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":22609.25,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":22609.25,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":22609.25,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":22609.25,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":33114.56,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":32331.23,"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":22289.53,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":22837.63,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":35398.33,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":23066.01,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":25121.39,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":23522.76,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":23522.76,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":23522.76,"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":10488.96,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":10746.89,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":16657.68,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":10854.36,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":11821.58,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":11069.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":11069.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":11069.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":11069.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":11069.30,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":10639.42,"methodology":"fee schedule"}]}]},{"description":"Drug metabolism or processing (mult conditions), whole blood or buccal specimen, DNA analysis, 25 gene report, with variant analysis and reported phenotypes ","code_information":[{"code":"0348U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":374.26,"maximum":4483.93,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":748.58,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":779.38,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":742.27,"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":12672.35,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":17554.36,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":19334.70,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":18690.08,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":16850.19,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":28105.71,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":17378.82,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":17378.82,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":17378.82,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":17378.82,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":17378.82,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":25453.82,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":24851.71,"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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"},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":19538.79,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":26357.87,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":22784.87,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":17203.27,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":18986.68,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":18432.08,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":17905.45,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":17905.45,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":17905.45,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":17905.45,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":17905.45,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":18783.17,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":27209.26,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":27209.26,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":27209.26,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":18432.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":18432.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":18432.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":18432.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":18432.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":18432.08,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":17554.36,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":17729.90,"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":17133.06,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":17554.36,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":27209.26,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":17729.90,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":19309.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":18080.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":18080.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":18080.99,"methodology":"fee 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schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":7.90,"methodology":"fee schedule"},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":9.43,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":12.18,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":7.94,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":10.22,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":8.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":8.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":8.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":8.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":8.10,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":7.90,"methodology":"fee schedule"}]}]},{"description":"OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"093","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":11615.96,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":7396.74,"methodology":"fee schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":7868.88,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":7494.17,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":7103.70,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":6977.22,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":6144.18,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10611.33,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":7419.23,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":7419.23,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":7419.23,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":7419.23,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":7419.23,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":10866.54,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":10609.49,"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":7644.05,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":10507.95,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":8878.84,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":11579.03,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":7261.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":7261.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":11579.03,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":7830.65,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7943.82,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":7494.17,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":10416.89,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":10855.24,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":7178.68,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":11252.49,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":8371.32,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":7344.28,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":6975.83,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":7868.88,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":7644.05,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":7644.05,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":7644.05,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":7644.05,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":7644.05,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":8018.76,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":11615.96,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":11615.96,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":11615.96,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":7868.88,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":7868.88,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":7868.88,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":7868.88,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":7868.88,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":7868.88,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":7494.17,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":7569.11,"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":7314.31,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":7494.17,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":11615.96,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":7569.11,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":8243.58,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":7718.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":7718.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":7718.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":7718.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":7718.99,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":7419.23,"methodology":"fee schedule"}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC ","code_information":[{"code":"964","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":26115.00,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":12590.87,"methodology":"fee schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":13394.55,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":12756.71,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":13501.80,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":13306.86,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":11718.09,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20237.76,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":12629.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":12629.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":12629.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":12629.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":12629.14,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":18497.23,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":18059.67,"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":13011.84,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":19972.16,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":16875.75,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":22007.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":12361.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":12361.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":22007.93,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":14883.48,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":13522.11,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":12756.71,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":17731.83,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":20632.25,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. 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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":14309.54,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":19432.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":24782.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":17897.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":14661.41,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":22725.19,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":14808.02,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":16127.55,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":15101.25,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":15101.25,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":15101.25,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":15101.25,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":15101.25,"methodology":"fee 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schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":3743.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":30079.56,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":3631.61,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":3856.25,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":5204.06,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":7675.06,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":7862.25,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":3669.05,"methodology":"fee schedule"},{"payer_name":"ProCare 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schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":3762.65,"methodology":"fee schedule"},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":4492.72,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":5803.09,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":3781.37,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":4867.11,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":3856.25,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":3856.25,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":3856.25,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":3856.25,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":3856.25,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":3762.65,"methodology":"fee schedule"}]}]},{"description":"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISOR ","code_information":[{"code":"622","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":54924.48,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":28985.00,"methodology":"fee schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross 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"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":29366.77,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":33696.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":30625.43,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":27610.61,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":46053.83,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":29073.10,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":29073.10,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":29073.10,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":29073.10,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":29073.10,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":42581.82,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":41574.54,"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":28661.97,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":29366.77,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":45518.49,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":29660.44,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":32303.45,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":30247.77,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":30247.77,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":30247.77,"methodology":"fee 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"},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":19425.10,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":26218.94,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":22652.29,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":17112.59,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":18876.20,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":18334.92,"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":17042.75,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":17461.83,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":27065.84,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":17636.45,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":19208.01,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":17985.68,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":17985.68,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":17985.68,"methodology":"fee 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schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":30.08,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":30.08,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":30.08,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":30.08,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":30.08,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":29.35,"methodology":"fee schedule"}]}]},{"description":"CHOLECYSTECTOMY WITH C.D.E. 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"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":17430.00,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":19183.50,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":19294.98,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":17395.54,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":29015.35,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":17255.70,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":17255.70,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":17255.70,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":17255.70,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":17255.70,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":25273.50,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":24675.65,"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":17011.68,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":17430.00,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":27016.50,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":17604.30,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":19173.00,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":17952.90,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":17952.90,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":17952.90,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":17952.90,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":17952.90,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":17255.70,"methodology":"fee schedule"}]}]},{"description":"Clotting; factor XIII (fibrin stabilizing), screen solubility ","code_information":[{"code":"85291","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6.86,"maximum":56.95,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":56.95,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":56.95,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":56.95,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":44.84,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":44.84,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":44.84,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":9.19,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":41.59,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":41.59,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":41.59,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":52.66,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":52.66,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":52.66,"methodology":"fee schedule"},{"payer_name":"Aetna Better 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"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":7183.26,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":6725.70,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":6942.44,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":6113.55,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10558.42,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":2696.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":2921.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3473.00,"methodology":"per diem"},{"payer_name":"Cigna Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":7111.42,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":7111.42,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":7111.42,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":7111.42,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":7111.42,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":10415.72,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":10169.34,"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":7326.92,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":9948.80,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":8406.38,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":9467.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":6960.58,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":6960.58,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":9467.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":7413.96,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7614.25,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":7183.26,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":9984.73,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":10277.62,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":6796.69,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":10785.66,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":7925.86,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":7039.59,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":6604.64,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":7542.42,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":7326.92,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":7326.92,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":7326.92,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":7326.92,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":7326.92,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared 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Plan","plan_name":"MCRPOS","standard_charge_dollar":7542.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":7542.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":7542.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":7542.42,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":7183.26,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":7255.09,"methodology":"fee schedule"},{"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":7010.86,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":7183.26,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":11134.05,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":7255.09,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":7901.58,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":7398.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":7398.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":7398.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":7398.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":7398.75,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":7111.42,"methodology":"fee schedule"}]}]},{"description":"OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC ","code_information":[{"code":"804","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":17401.57,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":9707.03,"methodology":"fee schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":10326.63,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":9834.89,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":9949.50,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":11571.90,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":10432.74,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17401.57,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":9736.54,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":9736.54,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":9736.54,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":9736.54,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":9736.54,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":14260.58,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":13923.25,"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":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":13788.64,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":14756.40,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":13188.22,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":11613.62,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20057.33,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13650.75,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13650.75,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":13650.75,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":13650.75,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":13650.75,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":19993.53,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":19520.58,"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. 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"},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":14912.16,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":20703.64,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":17389.60,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":13512.87,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":14490.78,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":14478.07,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":14064.41,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":14064.41,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":14064.41,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":14064.41,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":14064.41,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":14753.84,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":21372.39,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":21372.39,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":21372.39,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":14478.07,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":14478.07,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":14478.07,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":14478.07,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":14478.07,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":14478.07,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":13788.64,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":13926.53,"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":13457.71,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":13788.64,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":21372.39,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":13926.53,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15167.50,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":14202.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":14202.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":14202.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":14202.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":14202.30,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13650.75,"methodology":"fee schedule"}]}]},{"description":"Power wheelchair accessory, foam filled caster tire, any size, replacement only, each ","code_information":[{"code":"E2387","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":53.56,"maximum":115.96,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":55.69,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":57.98,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":55.22,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":55.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":55.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":55.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":55.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":55.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":55.22,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":80.07,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":109.34,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":55.22,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":55.22,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":55.22,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":53.56,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":56.88,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":76.76,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":113.20,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":115.96,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":54.12,"methodology":"fee 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"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":7496.06,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":10247.02,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":8658.36,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":11291.50,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":7121.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":7121.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":11291.50,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":7636.19,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7790.02,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":7349.08,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":10215.22,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":10585.68,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":7000.42,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":11034.64,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":8163.44,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":7202.09,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":6802.61,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":7716.53,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":7496.06,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":7496.06,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":7496.06,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":7496.06,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":7496.06,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":7863.51,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":11391.07,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":11391.07,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":11391.07,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":7716.53,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":7716.53,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":7716.53,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":7716.53,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":7716.53,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":7716.53,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":7349.08,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":7422.57,"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":7172.70,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":7349.08,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":11391.07,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":7422.57,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":8083.98,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":7569.55,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":7569.55,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":7569.55,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":7569.55,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":7569.55,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":7275.59,"methodology":"fee schedule"}]}]},{"description":"Rolapitant, oral, 1mg ","code_information":[{"code":"1761","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1.55,"maximum":3.32,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1.60,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":1.66,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":1.58,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1.58,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":1.58,"methodology":"fee schedule"},{"payer_name":"Cigna 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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":11087.92,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":16386.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":21812.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":15753.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":11360.57,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":17608.88,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":11474.18,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":12496.63,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":11701.39,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":11701.39,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":11701.39,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":11701.39,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":11701.39,"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":16048.59,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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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schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":62.79,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":60.10,"methodology":"fee schedule"},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":71.76,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":92.69,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":60.40,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":77.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":61.59,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":61.59,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":61.59,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":61.59,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":61.59,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":60.10,"methodology":"fee schedule"}]}]},{"description":"KIDNEY AND URINARY TRACT INFECTIONS WITH MCC ","code_information":[{"code":"689","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":23666.00,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":10181.22,"methodology":"fee schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":10831.09,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":10315.32,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":10533.60,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":16434.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 12.  If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":20572.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 12.  If billable gross charges exceed threshold of $492951.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10152 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":17478.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 12.  If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 21.8% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":15229.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 12.  If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":23666.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 12.  If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":10212.17,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":10212.17,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":10212.17,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":10212.17,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":10212.17,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":14957.21,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":14603.40,"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":10521.63,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":15435.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":13165.83,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":17169.77,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":9995.55,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":9995.55,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":17169.77,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":11611.54,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":10934.24,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":10315.32,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":14338.29,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":16096.51,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":10644.79,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":15488.45,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":12413.26,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":10109.01,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":10344.00,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":10831.09,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":10521.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":10521.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":10521.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":10521.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":10521.63,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":11037.39,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":15988.75,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":15988.75,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":15988.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":10831.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":10831.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":10831.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":10831.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":10831.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":10831.09,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":10315.32,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":10418.47,"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":10067.75,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":10315.32,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":15988.75,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":10418.47,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":11346.85,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":10624.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":10624.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":10624.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":10624.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":10624.78,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":10212.17,"methodology":"fee schedule"}]}]},{"description":"Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per lens ","code_information":[{"code":"V2782","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":74.00,"maximum":612.94,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":76.94,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":80.10,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":76.29,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":76.29,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":76.29,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":76.29,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":76.29,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":76.29,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":76.29,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":110.62,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":151.05,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":76.29,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":612.94,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":76.29,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":76.29,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":612.94,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":74.00,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":78.58,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":106.04,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":156.39,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":160.21,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":74.76,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":80.10,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":80.87,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":80.87,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":80.87,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":80.87,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":80.87,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":80.10,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":118.25,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":118.25,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":110.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":80.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":80.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":80.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":80.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":80.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":80.10,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":76.67,"methodology":"fee schedule"},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":91.55,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":118.25,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":77.05,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":99.18,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":78.58,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":78.58,"methodology":"fee 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"},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":9921.74,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":14604.80,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":11570.09,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":9532.27,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":9641.37,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":10213.15,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. 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schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":56.78,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":56.95,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":13.99,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":56.45,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":18.24,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":79.37,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":86.14,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":102.40,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":16.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":16.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":16.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":16.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":16.85,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":24.43,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":14.15,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":14.15,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":14.15,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":14.15,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":33.36,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":16.85,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":46.80,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":17.50,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":16.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":16.85,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":17.69,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":17.36,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":23.42,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":15.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":34.54,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":15.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":15.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":15.40,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":35.39,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":46.34,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":16.51,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":46.34,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":17.69,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":17.86,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":17.86,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":17.86,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":17.86,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":17.86,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":17.69,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":26.12,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":26.12,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":24.43,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":17.69,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":17.69,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":17.69,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":17.69,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":17.69,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":17.69,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"STAR","standard_charge_dollar":14.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"STARKIDS","standard_charge_dollar":14.00,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":13.72,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16.93,"methodology":"fee schedule"},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":20.22,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":26.12,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":17.02,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":21.91,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":17.36,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":17.36,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":17.36,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":17.36,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":17.36,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":16.93,"methodology":"fee schedule"}]}]},{"description":"APPENDIX PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"399","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":16490.55,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":9842.93,"methodology":"fee schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":10471.20,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":9972.57,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":10116.90,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":11002.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $492951.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10152 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9264.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 21.8% of billable gross charges, or (b) $9240 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":9872.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":9872.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":9872.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":9872.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":9872.85,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":14460.23,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":14118.17,"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":10172.03,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":14965.14,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":12645.00,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":16490.55,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":9663.42,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":9663.42,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":16490.55,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":11152.20,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":10570.93,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":9972.57,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":13861.88,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":15459.75,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":10223.69,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":14973.82,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":11922.20,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":9773.12,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":9934.80,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":10471.20,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":10172.03,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":10172.03,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":10172.03,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":10172.03,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":10172.03,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":10670.65,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":15457.49,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":15457.49,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":15457.49,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":10471.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":10471.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":10471.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":10471.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":10471.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":10471.20,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":9972.57,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":10072.30,"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":9733.23,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":9972.57,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":15457.49,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":10072.30,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":10969.83,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":10271.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":10271.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":10271.75,"methodology":"fee 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"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":15896.17,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":17318.70,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":16828.47,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":14819.24,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25593.62,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":15737.21,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":15737.21,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":15737.21,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":15737.21,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":15737.21,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":23049.45,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":22504.21,"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. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":16214.09,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":25618.21,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":21646.45,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":28229.48,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":15403.39,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":15403.39,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":28229.48,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":19090.98,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":16849.94,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":15896.17,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":22095.68,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":26464.90,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":17501.51,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":23868.10,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":20409.13,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":15578.25,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":17006.96,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":16690.98,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":16214.09,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":16214.09,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":16214.09,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":16214.09,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":16214.09,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":17008.90,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":24639.06,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":24639.06,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":24639.06,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":16690.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":16690.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":16690.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":16690.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":16690.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":16690.98,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":15896.17,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":16055.13,"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":15514.66,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":15896.17,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":24639.06,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":16055.13,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":17485.79,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":16373.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":16373.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":16373.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":16373.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":16373.06,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":15737.21,"methodology":"fee schedule"}]}]},{"description":"CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WI ","code_information":[{"code":"023","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":99388.00,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":43310.68,"methodology":"fee schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":46075.19,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":43881.13,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":51342.30,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":48052.34,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":43321.97,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":72260.01,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":43442.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":43442.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":43442.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":43442.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":43442.32,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":63627.64,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":62122.52,"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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schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13102.79,"methodology":"fee schedule"}]}]},{"description":"EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC ","code_information":[{"code":"982","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":35919.50,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":19519.54,"methodology":"fee schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":20765.47,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":19776.64,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":22036.50,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":21490.08,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":19374.55,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":32316.28,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":19578.87,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":19578.87,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":19578.87,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":19578.87,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":19578.87,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":28676.13,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":27997.79,"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":19302.00,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":19776.64,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":30653.79,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":19974.41,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":21754.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":20369.94,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":20369.94,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":20369.94,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":20369.94,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":20369.94,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":19578.87,"methodology":"fee schedule"}]}]},{"description":"Fetal congenital abnormalities, biochemical assays of three proteins (PAPP-A, hCG ºany form», DIA), utilizing maternal serum, algorithm reported as a risk score ","code_information":[{"code":"81509","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1457.62,"maximum":9303.19,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":9303.19,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":9303.19,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":9303.19,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":7324.99,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":7324.99,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":7324.99,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1500.01,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":6793.70,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":6793.70,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":6793.70,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":8602.34,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":8602.34,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":8602.34,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":1561.74,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":1487.37,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":1609.78,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":6965.79,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":7559.23,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":8986.30,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1487.37,"methodology":"fee schedule"},{"payer_name":"Cigna 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"},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":7072.27,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":11122.45,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":8247.23,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":7259.41,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":6872.43,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":7777.93,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":7555.71,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":7555.71,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":7555.71,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":7555.71,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":7555.71,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":7926.09,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":11481.71,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":11481.71,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":11481.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":7777.93,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":7777.93,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":7777.93,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":7777.93,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":7777.93,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":7777.93,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":7407.56,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":7481.63,"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":7229.78,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":7407.56,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":11481.71,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":7481.63,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":8148.31,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":7629.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":7629.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":7629.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":7629.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":7629.78,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":7333.48,"methodology":"fee schedule"}]}]},{"description":"Manual wheelchair accessory, foam propulsion tire, any size, each ","code_information":[{"code":"E2218","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":48.15,"maximum":104.24,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":50.06,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":52.12,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":49.64,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":49.64,"methodology":"fee schedule"},{"payer_name":"Cigna 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"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":12726.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":12726.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":12726.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":12726.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":12726.43,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13350.27,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":19339.18,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":19339.18,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":19339.18,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":13100.73,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":13100.73,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":13100.73,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":13100.73,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":13100.73,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":13100.73,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":12476.89,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":12601.66,"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":12177.44,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":12476.89,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":19339.18,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":12601.66,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":13724.58,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":12851.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":12851.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":12851.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":12851.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":12851.20,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":12352.12,"methodology":"fee schedule"}]}]},{"description":"New Technology - Level 11 ","code_information":[{"code":"1548","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":921.26,"maximum":1974.13,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":948.05,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":987.07,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":940.06,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":940.06,"methodology":"fee 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Plan","plan_name":"MCRPPO","standard_charge_dollar":9606.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":9606.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":9606.38,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":9194.67,"methodology":"fee schedule"},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":10978.72,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":14180.84,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":9240.42,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":11893.61,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":9423.40,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":9423.40,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":9423.40,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":9423.40,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":9423.40,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":9194.67,"methodology":"fee schedule"}]}]},{"description":"NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC ","code_information":[{"code":"070","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":25506.73,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of 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"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":14522.24,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":15648.30,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":14982.03,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":13193.26,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":22785.45,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":14377.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":14377.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":14377.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":14377.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":14377.02,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":21057.25,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":20559.14,"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":14173.71,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":14522.24,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":22509.47,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":14667.46,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15974.46,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":14957.91,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":14957.91,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":14957.91,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":14957.91,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":14957.91,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":14377.02,"methodology":"fee schedule"}]}]},{"description":"Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or detected ","code_information":[{"code":"0017U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":76.08,"maximum":1102.28,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":573.30,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":573.30,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":573.30,"methodology":"fee 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schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":94.41,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":94.41,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":94.41,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":94.41,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":94.41,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":92.12,"methodology":"fee schedule"}]}]},{"description":"Oncology (prostate), mRNA expression profiling of HOXC6 and DLX1, reverse transcription polymerase chain reaction (RT-PCR), first void urine following digital rectal examination, algorithn reporteed a 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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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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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Network","plan_name":"MCD","standard_charge_dollar":38.22,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":47.49,"methodology":"fee schedule"},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":56.70,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":73.24,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":47.72,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":61.43,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":48.67,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":48.67,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":48.67,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":48.67,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":48.67,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":47.49,"methodology":"fee schedule"}]}]},{"description":"BENIGN PROSTATIC HYPERTROPHY WITH MCC ","code_information":[{"code":"725","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":18529.68,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":10858.52,"methodology":"fee schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":11551.62,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":11001.54,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":11367.90,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":11466.66,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":10097.60,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17439.09,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":10891.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":10891.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":10891.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":10891.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":10891.52,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":15952.23,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":15574.88,"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":11221.57,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":16815.65,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":14208.61,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":18529.68,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":10660.49,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":10660.49,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":18529.68,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":12531.22,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":11661.63,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":11001.54,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":15292.14,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":17371.41,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":11487.89,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":16518.81,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":13396.44,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":10781.51,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":11163.28,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":11551.62,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":11221.57,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":11221.57,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":11221.57,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":11221.57,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":11221.57,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":11771.65,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":17052.39,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":17052.39,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":17052.39,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":11551.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":11551.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":11551.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":11551.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":11551.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":11551.62,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":11001.54,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":11111.56,"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":10737.50,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":11001.54,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":17052.39,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":11111.56,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":12101.69,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":11331.59,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":11331.59,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":11331.59,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":11331.59,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":11331.59,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":10891.52,"methodology":"fee schedule"}]}]},{"description":"Blood count; platelet, automated ","code_information":[{"code":"355590","type":"CDM"},{"code":"85049","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2.94,"maximum":27.98,"gross_charge":547.71,"discounted_cash":547.71,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":27.98,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":27.98,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":27.98,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":22.03,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":22.03,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":22.03,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":4.52,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":20.43,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":20.43,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":20.43,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":25.87,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":25.87,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":25.87,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":4.06,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":4.70,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":4.48,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":3.76,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"MCDCHIPBH","standard_charge_dollar":3.76,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":4.35,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":15.10,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15.14,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":3.72,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15.01,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":4.85,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":20.66,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":22.42,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26.65,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":4.48,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":4.48,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":4.48,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":4.48,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":4.48,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":6.50,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":3.76,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":3.76,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":3.76,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":3.76,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":8.87,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":4.48,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":12.44,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":3.75,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":4.48,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":4.48,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":4.70,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":4.61,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":6.23,"methodology":"fee schedule"},{"payer_name":"Molina 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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":9483.97,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9116.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11626.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":8396.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":9717.18,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":15061.63,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":9814.35,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":10688.90,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":10008.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":10008.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":10008.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":10008.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":10008.70,"methodology":"fee 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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":58080.65,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":59508.86,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":92238.73,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":60103.95,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":65459.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":61294.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":61294.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":61294.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":61294.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":61294.13,"methodology":"fee 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"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":21667.21,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":35232.85,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":29770.48,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":38824.15,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":20583.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":20583.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":38824.15,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":26255.93,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":22516.90,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":21242.36,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":29526.88,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":36397.31,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":24069.92,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":31895.40,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":28068.78,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":20817.51,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":23389.77,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":22304.48,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":21667.21,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":21667.21,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":21667.21,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":21667.21,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":21667.21,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":22729.33,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":32925.66,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":32925.66,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":32925.66,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":22304.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":22304.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":22304.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":22304.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":22304.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":22304.48,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":21242.36,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":21454.78,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9685.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"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":20732.54,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":7187.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":9167.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":6620.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":21242.36,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":32925.66,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":21454.78,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":23366.60,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":21879.63,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":21879.63,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":21879.63,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":21879.63,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":21879.63,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":21029.94,"methodology":"fee schedule"}]}]},{"description":"FRACTURES OF HIP AND PELVIS WITHOUT MCC ","code_information":[{"code":"536","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":11895.90,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":7554.56,"methodology":"fee schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":8036.77,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":7654.06,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":7298.10,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":6883.56,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":6061.70,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10468.88,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":7577.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":7577.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":7577.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":7577.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":7577.52,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":11098.39,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":10835.86,"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":7807.15,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":10795.51,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9121.81,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":11895.90,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":7416.79,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":7416.79,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":11895.90,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":8044.94,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":8113.31,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":7654.06,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":10639.15,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":11152.31,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":7375.14,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":11492.58,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":8600.41,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":7500.98,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":7166.73,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":8036.77,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":7807.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":7807.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":7807.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":7807.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":7807.15,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":8189.85,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":11863.80,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":11863.80,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":11863.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":8036.77,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":8036.77,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":8036.77,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":8036.77,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":8036.77,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":8036.77,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":7654.06,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":7730.61,"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":7470.37,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":7654.06,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":11863.80,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":7730.61,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":8419.47,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":7883.69,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":7883.69,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":7883.69,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":7883.69,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":7883.69,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":7577.52,"methodology":"fee schedule"}]}]},{"description":"Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer control, used for walking by spinal cord injured, entire system, after completi ","code_information":[{"code":"E0764","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR|KF","modifiers_description":"Rental (use the RR modifier when DME is to be rented)|Item designated by FDA as Class III device","setting":"outpatient","minimum":1464.68,"maximum":3170.96,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1522.81,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":1585.48,"methodology":"fee 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Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":2989.76,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":1509.98,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":1509.98,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":1509.98,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":1464.68,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":1555.28,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":2098.87,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":3095.46,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":3170.96,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":1479.78,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":1585.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":1600.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":1600.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":1600.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":1600.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":1600.58,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":1585.48,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":2340.47,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":2340.47,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":2189.47,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":1585.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":1585.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":1585.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":1585.48,"methodology":"fee schedule"},{"payer_name":"Superior Health 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schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":1555.28,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":1555.28,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":1555.28,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":1517.53,"methodology":"fee schedule"}]}]},{"description":"GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC ","code_information":[{"code":"379","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":10579.00,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":6281.05,"methodology":"fee schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":6681.97,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":6363.78,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":5729.40,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":5683.82,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":5005.21,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8644.26,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":6300.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":6300.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":6300.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":6300.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":6300.15,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":9227.49,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":9009.21,"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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schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":97.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":97.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":97.02,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":94.66,"methodology":"fee schedule"}]}]},{"description":"Ostomy pouch, closed; without barrier attached (1 piece), each ","code_information":[{"code":"A5052","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1.97,"maximum":16.27,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":2.05,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":2.13,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":2.03,"methodology":"fee 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schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":2.03,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":2.03,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":2.94,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":4.02,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":2.03,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":16.27,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":2.03,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":2.03,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":16.27,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":1.97,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":2.09,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":2.82,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":4.16,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":4.26,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":1.99,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":2.13,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of 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schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":2.94,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":2.13,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":2.13,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":2.13,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":2.13,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":2.13,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":2.13,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":2.04,"methodology":"fee schedule"},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":2.44,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":3.15,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":2.05,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":2.64,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":2.09,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":2.09,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":2.09,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":2.09,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":2.09,"methodology":"fee 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"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":8774.83,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":8660.70,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":8682.73,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":7646.06,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13205.14,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":8687.08,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":8687.08,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":8687.08,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":8687.08,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":8687.08,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":12723.50,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":12422.52,"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":8950.32,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":12811.10,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":10824.91,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":14116.94,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":8502.81,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":8502.81,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":14116.94,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":9546.98,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":9301.32,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":8774.83,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":12197.01,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":13234.51,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":8752.12,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":13175.40,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":10206.15,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":8599.33,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":8504.81,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":9213.57,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":8950.32,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":8950.32,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":8950.32,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":8950.32,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":8950.32,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":9389.06,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":13600.98,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":13600.98,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":13600.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":9213.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":9213.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":9213.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":9213.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":9213.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":9213.57,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":8774.83,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":8862.57,"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":8564.23,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":8774.83,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":13600.98,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":8862.57,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":9652.31,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":9038.07,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":9038.07,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":9038.07,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":9038.07,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":9038.07,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":8687.08,"methodology":"fee schedule"}]}]},{"description":"OTHER MENTAL DISORDER DIAGNOSES ","code_information":[{"code":"887","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":17447.03,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":10319.31,"methodology":"fee schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":10977.99,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":10455.23,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":10703.70,"methodology":"fee schedule"},{"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) $5535 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 $492951.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10152 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) 21.8% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"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) $4969 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 $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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":10350.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":10350.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":10350.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":10350.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":10350.68,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health 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gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":17447.03,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":10131.12,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":10131.12,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":17447.03,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":11082.54,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":10455.23,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":14532.77,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":1017.00,"methodology":"per diem"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":15698.53,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":12613.72,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":10246.13,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":10511.03,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":10977.99,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":10664.33,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":10664.33,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":10664.33,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":10664.33,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":10664.33,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":11187.10,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":10977.99,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":10977.99,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":10977.99,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":10977.99,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":10977.99,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":10977.99,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":10455.23,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":10559.78,"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":10204.30,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":10455.23,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":16205.61,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":10559.78,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":11500.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":10768.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":10768.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":10768.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":10768.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":10768.89,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":10350.68,"methodology":"fee schedule"}]}]},{"description":"Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each ","code_information":[{"code":"E1391","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":90.02,"maximum":194.88,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":93.59,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":97.44,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":92.80,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":92.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":92.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":92.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":92.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":92.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":92.80,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":134.56,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":183.74,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":92.80,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":92.80,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":92.80,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":90.02,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":95.58,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":128.99,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":190.24,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":194.88,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":90.94,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":97.44,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":98.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":98.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":98.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":98.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":98.37,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":97.44,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":143.84,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":143.84,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":134.56,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":97.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":97.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":97.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":97.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":97.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":97.44,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":93.26,"methodology":"fee schedule"},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":111.36,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":143.84,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":93.73,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":120.64,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":95.58,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":95.58,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":95.58,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":95.58,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":95.58,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":93.26,"methodology":"fee schedule"}]}]},{"description":"Partial Hospitalization ( ","code_information":[{"code":"5853","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":84.88,"maximum":181.88,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":87.34,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":90.94,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":86.61,"methodology":"fee schedule"},{"payer_name":"Cigna 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schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":86.61,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":86.61,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":89.21,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":120.39,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":177.55,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":181.88,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":84.88,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":90.94,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of 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"},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":9346.93,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":13902.33,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":10899.79,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":9073.78,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":9082.81,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":9721.91,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":9444.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":9444.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":9444.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":9444.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":9444.14,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":9907.09,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":14351.39,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":14351.39,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":14351.39,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":9721.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":9721.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":9721.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":9721.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":9721.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":9721.91,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":9258.96,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":9351.55,"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":9036.74,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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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","code_information":[{"code":"L6965","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":21484.72,"maximum":177951.94,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":22337.47,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":23256.66,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":22149.20,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":22149.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":22149.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":22149.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":22149.20,"methodology":"fee schedule"},{"payer_name":"Cigna 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Group","plan_name":"MCR","standard_charge_dollar":26579.04,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":34331.26,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":22370.69,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":28793.96,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":22813.68,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":22813.68,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":22813.68,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":22813.68,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":22813.68,"methodology":"fee 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"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":10108.04,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":10281.60,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":9356.48,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":8435.41,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14070.06,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":10006.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":10006.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":10006.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":10006.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":10006.96,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":14656.66,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":14309.95,"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":10310.20,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":10310.20,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":10310.20,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":10310.20,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":10310.20,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":10815.60,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":15667.46,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":15667.46,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":15667.46,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":10613.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":10613.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":10613.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":10613.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":10613.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":10613.44,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":10108.04,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":10209.12,"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":9865.45,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":10108.04,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":15667.46,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":10209.12,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":11118.84,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":10411.28,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":10411.28,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":10411.28,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":10411.28,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":10411.28,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":10006.96,"methodology":"fee schedule"}]}]},{"description":"Speech generating device, digitized speech, using pre-recorded messages, less than or equal to 8 minutes recording time ","code_information":[{"code":"E2500","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":517.55,"maximum":1120.48,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":538.10,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":560.24,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":533.56,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":533.56,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":533.56,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":533.56,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":533.56,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":533.56,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":533.56,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":773.66,"methodology":"fee schedule"},{"payer_name":"Corvel 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"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":13322.27,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":14189.40,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":14660.91,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":12910.48,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":22297.08,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13189.05,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13189.05,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":13189.05,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":13189.05,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":13189.05,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":19317.29,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":18860.34,"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":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":14339.18,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":20003.39,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":16721.42,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":13055.82,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":13933.99,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":13988.38,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":13588.72,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":13588.72,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":13588.72,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":13588.72,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":13588.72,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":14254.83,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":20649.52,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":20649.52,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":20649.52,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":13988.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":13988.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":13988.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":13988.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":13988.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":13988.38,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":13322.27,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":13455.49,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19901.00,"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":13002.54,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":14770.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 9. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":18836.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 9. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":13604.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 9. "},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":13322.27,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":20649.52,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":13455.49,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":14654.50,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":13721.94,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":13721.94,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":13721.94,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":13721.94,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":13721.94,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13189.05,"methodology":"fee schedule"}]}]},{"description":"Addition to lower extremity, above knee, flexible inner socket, external frame ","code_information":[{"code":"L5651","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1820.51,"maximum":15078.79,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1892.76,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":1970.65,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":1876.81,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":1876.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1876.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":1876.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":1876.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":1876.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":1876.81,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":2721.37,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":3716.08,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":1876.81,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":15078.79,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":1876.81,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":1876.81,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":15078.79,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":1820.51,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":1933.11,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":2608.77,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":3847.46,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":3941.30,"methodology":"fee 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Health","plan_name":"MGMCR","standard_charge_dollar":1970.65,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":2909.06,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":2909.06,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":2721.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":1970.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":1970.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":1970.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":1970.65,"methodology":"fee schedule"},{"payer_name":"Superior Health 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Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":3734.38,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":1886.05,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":15152.91,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":1886.05,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":1886.05,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":15152.91,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":1829.47,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":1942.63,"methodology":"fee 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"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":8678.50,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":8678.50,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":8678.50,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":8678.50,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":8678.50,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":9103.91,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":13187.91,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":13187.91,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":13187.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":8933.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":8933.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":8933.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":8933.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":8933.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":8933.75,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":8508.33,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":8593.41,"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":8304.13,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":8508.33,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":13187.91,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":8593.41,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":9359.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":8763.58,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":8763.58,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":8763.58,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":8763.58,"methodology":"fee 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schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":162.81,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":240.34,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":240.34,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":224.84,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":162.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":162.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":162.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":162.81,"methodology":"fee schedule"},{"payer_name":"Superior Health 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"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":16293.69,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":17802.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":17212.56,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":15518.12,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25883.86,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":16130.75,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":16130.75,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":16130.75,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":16130.75,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":16130.75,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":23625.85,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":23066.98,"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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Plan","plan_name":"MCRPPO","standard_charge_dollar":227.28,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":227.28,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":227.28,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":217.54,"methodology":"fee schedule"},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":259.75,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":335.51,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":218.62,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":281.39,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":222.95,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":222.95,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":222.95,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":222.95,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":222.95,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":217.54,"methodology":"fee schedule"}]}]},{"description":"RED BLOOD CELL DISORDERS WITHOUT MCC ","code_information":[{"code":"812","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":13538.94,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":8372.88,"methodology":"fee schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":8907.32,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":8483.16,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":8306.10,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":7852.28,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":6914.76,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11942.15,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":8398.33,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":8398.33,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":8398.33,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":8398.33,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":8398.33,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":12300.58,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":12009.61,"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":8652.83,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":12286.57,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":10381.70,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":13538.94,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":8220.18,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":8220.18,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":13538.94,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":9156.09,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":8992.15,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":8483.16,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":11791.60,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":12692.64,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":8393.78,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":12737.47,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":9788.28,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":8313.50,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":8156.59,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":8907.32,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":8652.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":8652.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":8652.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":8652.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":8652.83,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":9076.98,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":13148.90,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":13148.90,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":13148.90,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":8907.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":8907.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":8907.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":8907.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":8907.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":8907.32,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":8483.16,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":8567.99,"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":8279.57,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":8483.16,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":13148.90,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":8567.99,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":9331.48,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":8737.66,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":8737.66,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":8737.66,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":8737.66,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":8737.66,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":8398.33,"methodology":"fee schedule"}]}]},{"description":"Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each ","code_information":[{"code":"K0602","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":8.14,"maximum":17.62,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":8.46,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":8.81,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":8.39,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":8.39,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":8.39,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":8.39,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":8.39,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":8.39,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":8.39,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":12.17,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":16.61,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":8.39,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":8.39,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":8.39,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":8.14,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":8.64,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":11.66,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":17.20,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":17.62,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":8.22,"methodology":"fee schedule"},{"payer_name":"ProCare 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schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":13.00,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":12.17,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":8.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":8.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":8.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":8.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":8.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":8.81,"methodology":"fee 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"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":23238.12,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":26244.90,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":23774.97,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":21434.52,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":35752.26,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":23005.74,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":23005.74,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":23005.74,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":23005.74,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":23005.74,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":33695.27,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":32898.21,"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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"},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":26521.93,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":34892.04,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":30928.16,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":22773.36,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":25772.49,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":24400.03,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":23702.88,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":23702.88,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":23702.88,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":23702.88,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":23702.88,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":24864.79,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":36019.09,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":36019.09,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":36019.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":24400.03,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":24400.03,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":24400.03,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":24400.03,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":24400.03,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":24400.03,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":23238.12,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":23470.50,"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":22680.41,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":23238.12,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":36019.09,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":23470.50,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":25561.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":23935.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":23935.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":23935.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":23935.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":23935.26,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":23005.74,"methodology":"fee schedule"}]}]},{"description":"ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES ","code_information":[{"code":"278","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":73392.54,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":38183.04,"methodology":"fee schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":40620.26,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":38685.96,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":45026.10,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":11002.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $492951.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10152 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9264.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 21.8% of billable gross charges, or (b) $9240 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":38299.10,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":38299.10,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":38299.10,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":38299.10,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":38299.10,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":56094.64,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":54767.71,"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. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":39459.68,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":66603.61,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":56277.62,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":73392.54,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":37486.70,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":37486.70,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":73392.54,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":49633.77,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":41007.12,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":38685.96,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":53773.48,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":68804.88,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":45501.38,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":58086.97,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":53060.76,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":37912.24,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":44215.63,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":40620.26,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 6. 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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":37757.50,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":18188.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":23194.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":18688.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":38685.96,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":59963.24,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":39072.82,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":42554.56,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":39846.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":39846.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":39846.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":39846.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":39846.54,"methodology":"fee 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"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":9259.43,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":8818.50,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":8713.80,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":8711.09,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":8362.72,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $492951.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10152 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7787.60,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 21.8% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":6746.61,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8937.83,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":3204.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3471.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4128.00,"methodology":"per diem"},{"payer_name":"Cigna Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":8730.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":8730.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":8730.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":8730.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":8730.32,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":12786.83,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":12484.35,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":5333.00,"methodology":"per diem","additional_payer_notes":"Days 1 - 2. 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schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":12.65,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":35.50,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":13.56,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":13.68,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":13.68,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":13.68,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":13.68,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":13.68,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13.56,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":20.01,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":20.01,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":18.72,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":13.56,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":13.56,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":13.56,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":13.56,"methodology":"fee schedule"},{"payer_name":"Superior Health 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schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":16.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":13.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":13.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":13.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":13.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":13.30,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":12.97,"methodology":"fee schedule"}]}]},{"description":"OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC ","code_information":[{"code":"802","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":52586.08,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":27820.35,"methodology":"fee schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":29596.12,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":28186.78,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":32261.40,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":31445.52,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":28349.96,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":47287.06,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":27904.91,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":27904.91,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":27904.91,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":27904.91,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":27904.91,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":40870.83,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":39904.02,"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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"},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":32601.94,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":42322.45,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":38018.27,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":27623.04,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":31680.69,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":29596.12,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":28750.52,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":28750.52,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":28750.52,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":28750.52,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":28750.52,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":30159.85,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":43689.51,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":43689.51,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":43689.51,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":29596.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":29596.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":29596.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":29596.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":29596.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":29596.12,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":28186.78,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":28468.65,"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":27510.30,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":28186.78,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":43689.51,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":28468.65,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":31005.46,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":29032.38,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":29032.38,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":29032.38,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":29032.38,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":29032.38,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":27904.91,"methodology":"fee schedule"}]}]},{"description":"Paraffin bath unit, portable (see medical supply code a4265 for paraffin) ","code_information":[{"code":"E0235","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":22.83,"maximum":49.43,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":23.74,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":24.72,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":23.54,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":23.54,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":23.54,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":23.54,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":23.54,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":23.54,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":23.54,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":34.13,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":46.61,"methodology":"fee schedule"},{"payer_name":"Devoted 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Plan","plan_name":"MCRSNP","standard_charge_dollar":12.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":12.11,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"STAR","standard_charge_dollar":9.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"STARKIDS","standard_charge_dollar":9.00,"methodology":"fee schedule"},{"payer_name":"Texas Health Network","plan_name":"MCD","standard_charge_dollar":8.82,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11.59,"methodology":"fee schedule"},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":13.84,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":17.87,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":11.65,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":14.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":11.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":11.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":11.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":11.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":11.88,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":11.59,"methodology":"fee schedule"}]}]},{"description":"Traction frame, attached to footboard, pelvic traction ","code_information":[{"code":"E0890","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New 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schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":164.28,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":238.21,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":325.27,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":164.28,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":164.28,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":164.28,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":159.35,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":169.21,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":228.35,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":336.77,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":344.99,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":160.99,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":172.49,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":174.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":174.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":174.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":174.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":174.14,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":172.49,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":254.63,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":254.63,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":238.21,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":172.49,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":172.49,"methodology":"fee schedule"},{"payer_name":"Superior Health 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schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":169.21,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":169.21,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":169.21,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":169.21,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":169.21,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":165.10,"methodology":"fee schedule"}]}]},{"description":"TRAUMATIC INJURY WITHOUT MCC ","code_information":[{"code":"914","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":13442.12,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% 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"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":8434.31,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":8246.70,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":7911.15,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":6966.60,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12031.69,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":8349.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":8349.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":8349.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":8349.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":8349.96,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":12229.74,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":11940.45,"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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"},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":8333.75,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":12664.11,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":9718.28,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":8265.62,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":8098.26,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":8856.02,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":8602.99,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":8602.99,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":8602.99,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":8602.99,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":8602.99,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":9024.71,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":13073.17,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":13073.17,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":13073.17,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":8856.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":8856.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":8856.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":8856.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":8856.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":8856.02,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":8434.31,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":8518.65,"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":8231.88,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":8434.31,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":13073.17,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":8518.65,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":9277.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":8687.33,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":8687.33,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":8687.33,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":8687.33,"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":12488.84,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":12795.94,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":19833.71,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":12923.90,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":14075.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":13179.82,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":13179.82,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":13179.82,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":13179.82,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":13179.82,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":12667.98,"methodology":"fee schedule"}]}]},{"description":"Hematology (congenital coagulation disorders), genomic sequence analysis of 20 genes, blood, buccal swab, or amniotic fluid ","code_information":[{"code":"0270U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":498.00,"maximum":3675.19,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":613.34,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":638.58,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":608.17,"methodology":"fee 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"},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":16188.19,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":22263.09,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":18877.62,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":14530.69,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":15730.76,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":15568.59,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":15123.77,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":15123.77,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":15123.77,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":15123.77,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":15123.77,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":15865.14,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":22982.21,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":22982.21,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":22982.21,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":15568.59,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":15568.59,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":15568.59,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":15568.59,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":15568.59,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":15568.59,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":14827.23,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":14975.50,"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":14471.38,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":14827.23,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":22982.21,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":14975.50,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":16309.95,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":15272.05,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":15272.05,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":15272.05,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":15272.05,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":15272.05,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":14678.96,"methodology":"fee schedule"}]}]},{"description":"Peanut allergen-specific quantitative assessment of multiple epitopes using enzyme-linked immunosorbent assay (ELISA), blood, report of minimum eliciting exposure for a clinical reaction ","code_information":[{"code":"0178U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.38,"maximum":2778.43,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":463.77,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":482.85,"methodology":"fee 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schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":9536.91,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":9082.78,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":9035.10,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":9213.47,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":8113.43,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14012.32,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":8991.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":8991.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":8991.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":8991.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":8991.95,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":13170.03,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":12858.49,"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":9264.43,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":13364.92,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":11292.87,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":14727.21,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":8801.21,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":8801.21,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":14727.21,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":9959.69,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":9627.74,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":9082.78,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":12625.06,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":13806.64,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":9130.47,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":13637.79,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":10647.36,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":8901.12,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":8872.47,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":9536.91,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":9264.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":9264.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":9264.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":9264.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":9264.43,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":9718.57,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":14078.30,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":14078.30,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":14078.30,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":9536.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":9536.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":9536.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":9536.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":9536.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":9536.91,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":9082.78,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":9173.60,"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":8864.79,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":9082.78,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":14078.30,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":9173.60,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":9991.05,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":9355.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":9355.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":9355.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":9355.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":9355.26,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":8991.95,"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":5982.92,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":2873.23,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":2991.46,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","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":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":5641.04,"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":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":5982.92,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":2792.03,"methodology":"fee schedule"},{"payer_name":"ProCare 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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 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schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":533.95,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":572.09,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":577.54,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":577.54,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":577.54,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":577.54,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":577.54,"methodology":"fee schedule"},{"payer_name":"Shared 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"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":20187.48,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":22536.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":19582.08,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":17244.08,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":29781.44,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":19985.61,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":19985.61,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":19985.61,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":19985.61,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":19985.61,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":29271.85,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":28579.42,"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":20591.23,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":20591.23,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":20591.23,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":20591.23,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":20591.23,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":21600.60,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":31290.59,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":31290.59,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":31290.59,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":21196.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":21196.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":21196.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":21196.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":21196.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":21196.85,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":20187.48,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":20389.35,"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":19702.98,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":20187.48,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":31290.59,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":20389.35,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":22206.23,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":20793.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":20793.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":20793.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":20793.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":20793.10,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":19985.61,"methodology":"fee schedule"}]}]},{"description":"Dynamic adjustable forearm pronation/supination device, includes soft interface material ","code_information":[{"code":"E1802","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":432.54,"maximum":936.43,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":449.71,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":468.22,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":445.92,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":445.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":445.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":445.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":445.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":445.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":445.92,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":646.58,"methodology":"fee schedule"},{"payer_name":"Corvel 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schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11.95,"methodology":"fee schedule"},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":14.27,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":18.43,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":12.01,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15.46,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":12.25,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":12.25,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":12.25,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":12.25,"methodology":"fee 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"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":11882.46,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":12438.90,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":11841.30,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":10427.51,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":18008.86,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":11763.64,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":11763.64,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":11763.64,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":11763.64,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":11763.64,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":17229.57,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":16822.00,"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. 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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":11597.28,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":11882.46,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":18417.81,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":12001.28,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":13070.71,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":12238.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":12238.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":12238.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":12238.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":12238.93,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":11763.64,"methodology":"fee schedule"}]}]},{"description":"Genvisc 850, inj, 1mg ","code_information":[{"code":"9079","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":5.78,"maximum":12.38,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":5.95,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":6.19,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":5.90,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":5.90,"methodology":"fee schedule"},{"payer_name":"Cigna 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"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":12778.53,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":12778.53,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":12778.53,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":12778.53,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":12778.53,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13404.93,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":19418.35,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":19418.35,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":19418.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":13154.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":13154.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":13154.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":13154.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":13154.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":13154.37,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":12527.97,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":12653.25,"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":12227.30,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":12527.97,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":19418.35,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":12653.25,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":13780.77,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":12903.81,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":12903.81,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":12903.81,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":12903.81,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":12903.81,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":12402.69,"methodology":"fee schedule"}]}]},{"description":"HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC ","code_information":[{"code":"969","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":92771.61,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":47834.81,"methodology":"fee schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":50888.09,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 12. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":48464.85,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":56915.10,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":49577.30,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":44696.81,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":74553.21,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":47980.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":47980.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":47980.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":47980.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":47980.20,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":70274.03,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":68611.69,"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":49434.15,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":84190.08,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":71137.55,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":92771.61,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":46962.44,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":46962.44,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":92771.61,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":62739.41,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":51372.74,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":48464.85,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":67366.14,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":86972.60,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":57515.87,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":72769.97,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":67071.28,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":47495.55,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":55890.63,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":50888.09,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 12. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":49434.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":49434.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":49434.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":49434.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":49434.15,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":51857.39,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":75120.52,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":75120.52,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":75120.52,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":50888.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":50888.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":50888.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":50888.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":50888.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":50888.09,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":48464.85,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":48949.50,"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":47301.69,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":48464.85,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":75120.52,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":48949.50,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":53311.33,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":49918.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":49918.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":49918.80,"methodology":"fee 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"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":6746.50,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":6194.70,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":6347.47,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":5589.62,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9653.57,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":6679.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":6679.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":6679.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":6679.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":6679.04,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":9782.43,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":9551.02,"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. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":6881.43,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":9163.34,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":7742.69,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":10097.36,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":6537.36,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":6537.36,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":10097.36,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":6828.62,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7151.29,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":6746.50,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":9377.64,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":9466.19,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":6260.09,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":10129.87,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":7300.11,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":6611.57,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":6083.20,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":7083.83,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":6881.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":6881.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":6881.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":6881.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":6881.43,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":7218.76,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":10457.08,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":10457.08,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":10457.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":7083.83,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":7083.83,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":7083.83,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":7083.83,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":7083.83,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":7083.83,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":6746.50,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":6813.97,"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":6584.58,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":6746.50,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":10457.08,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":6813.97,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":7421.15,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":6948.90,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":6948.90,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":6948.90,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":6948.90,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":6948.90,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6679.04,"methodology":"fee schedule"}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC ","code_information":[{"code":"658","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":22062.21,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":12617.91,"methodology":"fee schedule"},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":13423.31,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":12784.10,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":13535.10,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":11002.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $492951.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10152 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9264.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 21.8% of billable gross charges, or (b) $9240 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":12656.26,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":12656.26,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":12656.26,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":12656.26,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":12656.26,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":18536.94,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":18098.45,"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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service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":37545.95,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":37921.41,"methodology":"fee schedule"},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":37545.95,"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":43674.75,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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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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":36112.37,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":37000.38,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":57350.59,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":37370.38,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":40700.42,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":38110.39,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":38110.39,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":38110.39,"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":14009.70,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":14354.20,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":22249.01,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":14497.74,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15789.62,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":14784.83,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":14784.83,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":14784.83,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":14784.83,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":14784.83,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":14210.66,"methodology":"fee schedule"}]}]},{"description":"Obstetrics (preeclampsia), kinase insert domain receptor, Endoglin, and retinol-binding protein 4, by immunoassay, serum, algorithm reported as a risk score ","code_information":[{"code":"0390U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.39,"maximum":177.13,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":64.96,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":67.63,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":64.41,"methodology":"fee 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"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":11681.84,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":12195.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":11429.58,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":10304.43,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17187.53,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":11565.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":11565.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":11565.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":11565.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":11565.02,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":16938.67,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":16537.98,"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":11915.48,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":18039.11,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":15242.40,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":19877.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":11319.70,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":11319.70,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":19877.85,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":13442.95,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":12382.75,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":11681.84,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":16237.76,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":18635.31,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":12323.73,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":17540.28,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":14371.13,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":11448.20,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":11975.49,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":12265.93,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":11915.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":11915.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":11915.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":11915.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":11915.48,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":12499.57,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":18106.85,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":18106.85,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":18106.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":12265.93,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":12265.93,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":12265.93,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":12265.93,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":12265.93,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":12265.93,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":11681.84,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":11798.66,"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":11401.48,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":11681.84,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":18106.85,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":11798.66,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":12850.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":12032.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":12032.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":12032.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":12032.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":12032.30,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":11565.02,"methodology":"fee schedule"}]}]},{"description":"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"272","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":60290.00,"payers_information":[{"payer_name":"Accountable Health Plans","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":27384.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":27384.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":32216.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":21545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":21545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":25345.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":19910.44,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":19989.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":19989.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":23515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":25346.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":25346.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":29819.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Affiliated PPO","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":21181.31,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":20172.68,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":22518.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":28845.46,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $477476.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $9624 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":45620.45,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $713575.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $11843 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":41090.67,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $682847.00, reimbursement will be the lesser of (a) 21.8% of billable gross charges, or (b) $10638 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":21081.65,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $405854.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $8944 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":50150.24,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $744303.00, reimbursement will be the lesser of (a) 27.3% of billable gross charges, or (b) $13047 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":19970.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":19970.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":19970.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":19970.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":19970.95,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":29250.39,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":28558.46,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_dollar":19919.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 8. "},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":20576.13,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":33309.13,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":28145.00,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":36704.34,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":19547.33,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":19547.33,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":36704.34,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":24822.34,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":21383.04,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":20172.68,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":28040.03,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":34410.01,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":28050.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":22755.69,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":30289.28,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":26536.21,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":19769.23,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":22112.68,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":21181.31,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":20576.13,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":20576.13,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":20576.13,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":20576.13,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":20576.13,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":21584.77,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":31267.65,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":31267.65,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":31267.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":21181.31,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":21181.31,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":21181.31,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":21181.31,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":21181.31,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":21181.31,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":20172.68,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":20374.41,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":60290.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7. "},{"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":19688.54,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":44745.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":57065.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":41213.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":20172.68,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":31267.65,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":20374.41,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":22189.95,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":20777.86,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":20777.86,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":20777.86,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":20777.86,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":20777.86,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":19970.95,"methodology":"fee schedule"}]}]},{"description":"Partial Hospitalization ( ","code_information":[{"code":"5863","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":251.16,"maximum":538.20,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":258.46,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":269.10,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":256.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":256.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":256.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":256.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":256.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":256.28,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":371.61,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":507.44,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":256.28,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":256.28,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":256.28,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":263.97,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":356.24,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":525.38,"methodology":"fee schedule"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":538.20,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":251.16,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":269.10,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":271.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":271.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":271.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":271.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":271.66,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":269.10,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":397.24,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":397.24,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":371.61,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":269.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":269.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":269.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":269.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":269.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":269.10,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":257.57,"methodology":"fee schedule"},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":307.54,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":397.24,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":258.85,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":281.91,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":263.97,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":263.97,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":263.97,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":263.97,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":263.97,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":257.57,"methodology":"fee schedule"}]}]},{"description":"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHE ","code_information":[{"code":"041","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":250.00,"maximum":33133.66,"payers_information":[{"payer_name":"Accountable Health 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"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":18370.88,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":20327.40,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":19906.66,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":17947.01,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":29935.18,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":18187.17,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":18187.17,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":18187.17,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":18187.17,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":18187.17,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":26637.78,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":26007.65,"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":"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":17929.98,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":19432.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":24782.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":17897.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":18370.88,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":28474.86,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":18554.59,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":20207.97,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":18922.01,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":18922.01,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":18922.01,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":18922.01,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":18922.01,"methodology":"fee 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"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":30232.13,"methodology":"fee schedule"},{"payer_name":"Averde Health","plan_name":"Commercial","standard_charge_dollar":34748.10,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":31575.14,"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) $5535 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":28466.83,"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) $4969 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":47481.98,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $544676.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11064 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":"Beech Street","plan_name":"COMMPPO","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Beech Street","plan_name":"WCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% 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 Behavioral Health","plan_name":"COMMBH","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":29929.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":29929.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":29929.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":29929.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":29929.81,"methodology":"fee schedule"},{"payer_name":"Coastal Comp","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":43836.59,"methodology":"fee schedule"},{"payer_name":"Corvel Corporation","plan_name":"WORKERSCOMP","standard_charge_dollar":42799.63,"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":30836.77,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":51400.16,"methodology":"fee schedule"},{"payer_name":"Galaxy Health Network","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":43431.26,"methodology":"fee schedule"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCEL","standard_charge_percentage":43.00,"standard_charge_algorithm":"Reimbursement will be 43% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"ACCOUNTABLEPPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"HealthSmart Preferred Care","plan_name":"PPO","standard_charge_percentage":82.00,"standard_charge_algorithm":"Reimbursement will be 82% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":56639.40,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":29294.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":29294.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":56639.40,"methodology":"fee schedule"},{"payer_name":"Imagine Health","plan_name":"PPO","standard_charge_dollar":38303.99,"methodology":"case rate"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":32046.06,"methodology":"fee schedule"},{"payer_name":"Independent Medical System","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":30232.13,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":42022.66,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":53098.96,"methodology":"fee schedule"},{"payer_name":"Multiplan","plan_name":"COMPLEMENTARYPPO","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Multiplan","plan_name":"PRIMARYPPO","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"Multiplan","plan_name":"SAVILITYNETWORK","standard_charge_dollar":35114.89,"methodology":"fee schedule"},{"payer_name":"National Healthcare Alliance","plan_name":"EPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Alliance","plan_name":"PPO","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"National Healthcare Solutions","plan_name":"COMM","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"OMNI Healthcare","plan_name":"WORKERSCOMP","standard_charge_dollar":45393.54,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":40948.71,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":29627.49,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":34122.63,"methodology":"fee schedule"},{"payer_name":"Physicians Cooperative of Texas","plan_name":"WC","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Physicians, INC","plan_name":"COMM","standard_charge_percentage":85.00,"standard_charge_algorithm":"Reimbursement will be 85% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":31743.74,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":30836.77,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":30836.77,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":30836.77,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":30836.77,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":30836.77,"methodology":"fee schedule"},{"payer_name":"Rockport Workers Comp","plan_name":"COMM","standard_charge_percentage":55.00,"standard_charge_algorithm":"Reimbursement will be 55% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":32348.38,"methodology":"fee schedule"},{"payer_name":"SouthWest Medical","plan_name":"WORKERSCOMP","standard_charge_percentage":60.00,"standard_charge_algorithm":"Reimbursement will be 60% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":46859.80,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":46859.80,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":46859.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":31743.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":31743.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":31743.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":31743.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":31743.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":31743.74,"methodology":"fee schedule"},{"payer_name":"Texas Athletic Network","plan_name":"Premier","standard_charge_dollar":250.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"PremierPlus","standard_charge_dollar":750.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Texas Athletic Network","plan_name":"TexasCustomUC","standard_charge_percentage":100.00,"standard_charge_algorithm":"Reimbursement will be 100% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_percentage":27.03,"standard_charge_algorithm":"Reimbursement will be 27.03% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Texas Healthcare Foundation","plan_name":"WORKERSCOMP","standard_charge_dollar":30232.13,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":30534.45,"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":29506.56,"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":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% 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":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":30232.13,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":46859.80,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":30534.45,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":33255.34,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":31139.09,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":31139.09,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":31139.09,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":31139.09,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":31139.09,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":29929.81,"methodology":"fee schedule"}]}]},{"description":"Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing ","code_information":[{"code":"A6253","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8.38,"maximum":69.45,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":8.71,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":9.07,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"DualEligible","standard_charge_dollar":8.64,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":9.35,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13.69,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12.59,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":15.01,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.79,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":8.64,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":8.64,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":8.64,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":8.64,"methodology":"fee 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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":30372.11,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":29096.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 9. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":37107.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 9. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":25.70,"standard_charge_algorithm":"Reimbursement will be 25.7% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":26799.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 9. "},{"payer_name":"Universal Healthcare Group","plan_name":"MCR","standard_charge_dollar":31118.97,"methodology":"fee schedule"},{"payer_name":"UTMB","plan_name":"MGMCR","standard_charge_dollar":48234.40,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":31430.16,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":34230.87,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":32052.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":32052.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":32052.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":32052.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":32052.54,"methodology":"fee 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