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charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":27000.00,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":20700.00,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","estimated_amount":17100.00,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":80000.00,"methodology":"percent of total billed 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IPA","plan_name":"MCR","standard_charge_dollar":151.37,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":301.27,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":144.02,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":154.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":155.78,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":155.78,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":155.78,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":155.78,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":155.78,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":154.31,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":146.96,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":191.05,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":147.69,"methodology":"fee schedule"}]}]},{"description":"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC ","code_information":[{"code":"146","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":31798.04,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":21104.73,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"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":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":20099.74,"methodology":"fee schedule"},{"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":19898.74,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":19898.74,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":19898.74,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":19898.74,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":19898.74,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":29144.62,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":20501.73,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":30538.69,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":25804.08,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":19476.65,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":19476.65,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":21305.72,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":20099.74,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":31798.04,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":24329.10,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":19697.75,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":20273.49,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":21104.73,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":20501.73,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":20501.73,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":20501.73,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":20501.73,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":20501.73,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":21506.72,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":20300.74,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":20099.74,"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":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":22109.71,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":19898.74,"methodology":"fee schedule"}]}]},{"description":"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH ","code_information":[{"code":"003","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10033.00,"maximum":297065.43,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":184406.25,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 24. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":139680.31,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary 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charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":24410.80,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":13731.08,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":5645.00,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"EXTENDER TIP M/F 3D 180 ","code_information":[{"code":"605822","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":14346.00,"discounted_cash":14346.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":6383.97,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":6383.97,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":6383.97,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":5035.45,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":5035.45,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":5035.45,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":4662.45,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":4662.45,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":4662.45,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":5910.55,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":5910.55,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":5910.55,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":4318.15,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":4016.88,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":4289.45,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":4332.49,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":3844.73,"methodology":"percent of total billed charges"},{"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":5422.79,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":4303.80,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":5738.40,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":3443.04,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":3744.31,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":4447.26,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":1864.98,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":1864.98,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":1864.98,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":1864.98,"methodology":"percent of total billed charges"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_percentage":28.10,"standard_charge_algorithm":"Reimbursement will be 28.1% of billable gross charges.","estimated_amount":4031.23,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":26.00,"standard_charge_algorithm":"Reimbursement will be 26% of billable gross charges.","estimated_amount":3729.96,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":2725.74,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":3873.42,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":2969.62,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","estimated_amount":2453.17,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":11476.80,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":6455.70,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":2654.01,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC ","code_information":[{"code":"981","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":68253.07,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":42100.80,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 8. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":33736.61,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":30792.56,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":68253.07,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":40096.00,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":39695.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":39695.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":39695.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":39695.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":39695.04,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":58139.20,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":40897.92,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":63294.00,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":53481.12,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":38853.02,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":38853.02,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":42501.76,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":40096.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":65904.11,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":50424.11,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":39294.08,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":42018.50,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":42100.80,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 8. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":40897.92,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":40897.92,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":40897.92,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":40897.92,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":40897.92,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":42902.72,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":40496.96,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":40096.00,"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":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":44105.60,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":39695.04,"methodology":"fee schedule"}]}]},{"description":"External urinary catheter; non-disposable, for use with suction pump, per month ","code_information":[{"code":"A6591","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":85.04,"maximum":196.23,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":91.12,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":107.42,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":157.32,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":144.63,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":196.23,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":170.01,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":86.78,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":86.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":86.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":86.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":86.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":86.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":86.78,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":125.83,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":86.78,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":86.78,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":86.78,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":89.38,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":177.90,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":85.04,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":91.12,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":91.99,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":91.99,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":91.99,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":91.99,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":91.99,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":91.12,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":86.78,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":112.81,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":87.21,"methodology":"fee schedule"}]}]},{"description":"EXTRACTOR STON 10F 38CM ","code_information":[{"code":"600413","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":7469.50,"discounted_cash":7469.50,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":3323.93,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":3323.93,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":3323.93,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":2621.79,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":2621.79,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":2621.79,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":2427.59,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":2427.59,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":2427.59,"methodology":"percent of total billed 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$8633.","estimated_amount":911.64,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":991.41,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":1177.54,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":493.81,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":493.81,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":493.81,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":493.81,"methodology":"percent of total billed charges"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_percentage":28.10,"standard_charge_algorithm":"Reimbursement will be 28.1% of billable gross charges.","estimated_amount":1067.38,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":26.00,"standard_charge_algorithm":"Reimbursement will be 26% of billable gross charges.","estimated_amount":987.61,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":721.72,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":1025.60,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":786.29,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","estimated_amount":649.54,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":3038.80,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":1709.33,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":702.72,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"HARVESTER BN GRAFT 0MM ","code_information":[{"code":"109669","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":18707.00,"discounted_cash":18707.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":8324.61,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":8324.61,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":8324.61,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":6566.16,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":6566.16,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":6566.16,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross 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gross charges not to exceed $11123.","estimated_amount":5799.17,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":2431.91,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":2431.91,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":2431.91,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":2431.91,"methodology":"percent of total billed charges"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_percentage":28.10,"standard_charge_algorithm":"Reimbursement will be 28.1% of billable gross charges.","estimated_amount":5256.67,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":26.00,"standard_charge_algorithm":"Reimbursement will be 26% of billable gross charges.","estimated_amount":4863.82,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":3554.33,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":5050.89,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":3872.35,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","estimated_amount":3198.90,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":14965.60,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":8418.15,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":3460.80,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"HEADACHES WITH MCC ","code_information":[{"code":"102","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":16641.54,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":11423.36,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":9690.65,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":8560.61,"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) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16641.54,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":10879.39,"methodology":"fee schedule"},{"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":10770.60,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":10770.60,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":10770.60,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":10770.60,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":10770.60,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":15775.12,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":11096.98,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":15435.09,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":13042.09,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":10542.13,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":10542.13,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":11532.15,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":10879.39,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":16071.60,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":12296.60,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":10661.80,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":10246.78,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":11423.36,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":11096.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":11096.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":11096.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":11096.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":11096.98,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":11640.95,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":10988.18,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":10879.39,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":11967.33,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":10770.60,"methodology":"fee schedule"}]}]},{"description":"HEART FAILURE AND SHOCK WITH CC ","code_information":[{"code":"292","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4523.00,"maximum":14421.00,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":8879.49,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":7256.85,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":6410.62,"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) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12462.03,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":8456.66,"methodology":"fee schedule"},{"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":8372.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":8372.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":8372.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":8372.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":8372.09,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":12262.16,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":8625.79,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":11466.49,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9688.76,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":8194.50,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":8194.50,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":8964.06,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":8456.66,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":11939.34,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":9134.95,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":8287.53,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":7612.17,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":8879.49,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. 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"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":9302.33,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":8372.09,"methodology":"fee schedule"}]}]},{"description":"Heavy duty wheelchair ","code_information":[{"code":"K0006","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":71.12,"maximum":148.77,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":76.20,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":72.57,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":72.57,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":72.57,"methodology":"fee 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","code_information":[{"code":"88441","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":9667.00,"discounted_cash":9667.00,"payers_information":[{"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":3654.13,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":2900.10,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":3866.80,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice 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Texas","plan_name":"MCRHMO","standard_charge_dollar":7196.89,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":7196.89,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":7196.89,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":7196.89,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":7196.89,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":7129.00,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":6789.52,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":8826.38,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6823.47,"methodology":"fee schedule"}]}]},{"description":"Hip knee ankle foot orthosis, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated ","code_information":[{"code":"L2080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":414.34,"maximum":866.74,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":443.94,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":422.80,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":422.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":422.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":422.80,"methodology":"fee 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","code_information":[{"code":"G0475","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":23.60,"maximum":150.61,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":150.61,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":150.61,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":150.61,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":118.58,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":118.58,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":118.58,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":109.98,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":109.98,"methodology":"fee 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schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":78.02,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":24.08,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":26.06,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":112.70,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":122.30,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":145.39,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":24.08,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":24.08,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":24.08,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":24.08,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":24.08,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":34.92,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":24.08,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":24.08,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":24.08,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":24.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":49.36,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":66.22,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":23.60,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":66.22,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":25.28,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":25.52,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":25.52,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":25.52,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":25.52,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":25.52,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":25.28,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":24.08,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":31.30,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":24.20,"methodology":"fee schedule"}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC ","code_information":[{"code":"976","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":13930.84,"payers_information":[{"payer_name":"American Health 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":7980.44,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":7049.83,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13704.63,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":9607.48,"methodology":"fee schedule"},{"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":9511.40,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":9511.40,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":9511.40,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":9511.40,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":9511.40,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":13930.84,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":9799.63,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":13351.61,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":11281.62,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":9309.65,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":9309.65,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":10183.93,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":9607.48,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":13902.20,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":10636.76,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":9415.33,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":8863.63,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":10087.85,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":9799.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":9799.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":9799.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":9799.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":9799.63,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":10280.00,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":9703.55,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":9607.48,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":15515.40,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":14161.44,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":31389.46,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":17696.52,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":17519.55,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":17519.55,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":17519.55,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":17519.55,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":17519.55,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":25659.95,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":18050.45,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":26602.04,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":22477.75,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":17147.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":17147.93,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":18758.31,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":17696.52,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":27699.05,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":21192.91,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":17342.59,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":17660.09,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":18581.35,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":18050.45,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":18050.45,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":18050.45,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":18050.45,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":18050.45,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":18935.28,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":17873.49,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":17696.52,"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":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":19466.17,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":17519.55,"methodology":"fee schedule"}]}]},{"description":"INSERT KIT PERC FT 1.8MM ","code_information":[{"code":"101042","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":7854.00,"discounted_cash":7854.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":3495.03,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":3495.03,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":3495.03,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":2756.75,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":2756.75,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":2756.75,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":2552.55,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":2552.55,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":2552.55,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":3235.85,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":3235.85,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":3235.85,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":2364.05,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":2199.12,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":2348.35,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":2371.91,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":2104.87,"methodology":"percent of total billed charges"},{"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":2968.81,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":2356.20,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":3141.60,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":1884.96,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":2049.89,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":2434.74,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":1021.02,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":1021.02,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":1021.02,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":1021.02,"methodology":"percent of total billed charges"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_percentage":28.10,"standard_charge_algorithm":"Reimbursement will be 28.1% of billable gross charges.","estimated_amount":2206.97,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":26.00,"standard_charge_algorithm":"Reimbursement will be 26% of billable gross charges.","estimated_amount":2042.04,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":1492.26,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":2120.58,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":1625.78,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","estimated_amount":1343.03,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":6283.20,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":3534.30,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":1452.99,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"Insertion tray with drainage bag but without catheter ","code_information":[{"code":"A4354","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":15.79,"maximum":33.03,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":16.92,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":17.41,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":25.50,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":23.44,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":31.81,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":27.56,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":16.11,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":16.11,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":16.11,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":16.11,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":16.11,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":16.11,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":16.11,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":23.36,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":16.11,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":16.11,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":16.11,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":16.59,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":33.03,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":15.79,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":16.92,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":17.08,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":17.08,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":17.08,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":17.08,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":17.08,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":16.92,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":16.11,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":20.94,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":16.19,"methodology":"fee schedule"}]}]},{"description":"INST BN REMOVER SCREW ","code_information":[{"code":"601476","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":6218.00,"discounted_cash":6218.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":2767.01,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":2767.01,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":2767.01,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":2182.52,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":2182.52,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":2182.52,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":2020.85,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":2020.85,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":2020.85,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":2561.82,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":2561.82,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":2561.82,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":1871.62,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":1741.04,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":1859.18,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":1877.84,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":1666.42,"methodology":"percent of total billed charges"},{"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":2350.40,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":1865.40,"methodology":"percent of total billed 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37.8% of billable gross charges.","estimated_amount":19516.14,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":15489.00,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":20652.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":6711.90,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":6711.90,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":6711.90,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":6711.90,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":13940.10,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":41304.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":23233.50,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":9551.55,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"INTERBDY 12 MM 12 DEG SM ","code_information":[{"code":"609398","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":100000.00,"discounted_cash":100000.00,"payers_information":[{"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":37800.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":30000.00,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":40000.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":13000.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":13000.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":13000.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":13000.00,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":27000.00,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":80000.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":45000.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":18500.00,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"INTERBDY 18 MM 24 DEG LG ","code_information":[{"code":"612693","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":63711.00,"discounted_cash":63711.00,"payers_information":[{"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":24082.76,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":19113.30,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":25484.40,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":8282.43,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":8282.43,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":8282.43,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":8282.43,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":17201.97,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":50968.80,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":28669.95,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":11786.53,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue shaping ","code_information":[{"code":"L6570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5027.58,"maximum":10516.87,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":5386.69,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":5130.18,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":5130.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":5130.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":5130.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":5130.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":5130.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":5130.18,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":7438.76,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":5130.18,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":5130.18,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":5130.18,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":5284.09,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":10516.87,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":5027.58,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":5386.69,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":5437.99,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":5437.99,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":5437.99,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":5437.99,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":5437.99,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":5386.69,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":5130.18,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":6669.23,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":5155.83,"methodology":"fee schedule"}]}]},{"description":"INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC ","code_information":[{"code":"198","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":12495.00,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":7506.44,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":6247.53,"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) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":5519.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10728.75,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":7148.99,"methodology":"fee schedule"},{"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":7077.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":7077.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":7077.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":7077.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":7077.50,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":10366.03,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":7291.97,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":9324.43,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":7878.80,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":6927.37,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":6927.37,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7577.93,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":7148.99,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":9708.94,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":7428.44,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":7006.01,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":6190.14,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":7506.44,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":7291.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":7291.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":7291.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":7291.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":7291.97,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":7649.42,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":7220.48,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":7148.99,"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":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":7863.89,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":7077.50,"methodology":"fee schedule"}]}]},{"description":"INTRAOCULAR PROCEDURES WITH CC/MCC ","code_information":[{"code":"116","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":27847.02,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":15767.82,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":13764.42,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":12563.26,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":27847.02,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":15016.97,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":14866.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":14866.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":14866.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":14866.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":14866.80,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":21774.61,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":15317.31,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":22212.74,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":18768.96,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":14551.44,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":14551.44,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":15917.99,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":15016.97,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":23128.75,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":17696.11,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":14716.63,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":14746.20,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":15767.82,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":15317.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":15317.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":15317.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":15317.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":15317.31,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":16068.16,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":15167.14,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":15016.97,"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":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":16518.67,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":14866.80,"methodology":"fee schedule"}]}]},{"description":"INTRO TROCAR TIP ","code_information":[{"code":"49875","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":11372.50,"discounted_cash":11372.50,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":5060.76,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross 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charges.","estimated_amount":3184.30,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":3400.38,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":3434.49,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":3047.83,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross 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charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":2160.78,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":3070.57,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":2354.11,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","estimated_amount":1944.70,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":9098.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":5117.63,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":2103.91,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"INTUBATION VIDEO ASSIST ","code_information":[{"code":"400799","type":"CDM"}],"standard_charges":[{"setting":"outpatient","gross_charge":2711.42,"discounted_cash":2711.42,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":1206.58,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":1206.58,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":1206.58,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":951.71,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":951.71,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":951.71,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":881.21,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":881.21,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":881.21,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":1117.11,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":1117.11,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":1117.11,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":816.14,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":759.20,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":810.71,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":818.85,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":726.66,"methodology":"percent of total billed charges"},{"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":1024.92,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":813.43,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":1084.57,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":650.74,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":707.68,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":840.54,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":352.48,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":352.48,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":352.48,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice 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charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":561.26,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","estimated_amount":463.65,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":2169.14,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":1220.14,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":501.61,"methodology":"percent of total billed charges"}]}]},{"description":"Iris supported intraocular lens ","code_information":[{"code":"V2631","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":136.73,"maximum":286.02,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":146.50,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":139.52,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":139.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":139.52,"methodology":"fee schedule"},{"payer_name":"Cigna 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","code_information":[{"code":"807811","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":248.42,"discounted_cash":248.42,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":110.55,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":110.55,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":110.55,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":87.20,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":87.20,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":87.20,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":80.74,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":80.74,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":80.74,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":102.35,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":102.35,"methodology":"percent of total billed 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charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":75.02,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":66.58,"methodology":"percent of total billed charges"},{"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":93.90,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":74.53,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":99.37,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":59.62,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":64.84,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":77.01,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":32.29,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":32.29,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":32.29,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross 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charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":185.30,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":185.30,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":146.16,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":146.16,"methodology":"percent of total billed 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charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":171.56,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":171.56,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":171.56,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":125.34,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":116.59,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":124.51,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":125.76,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":111.60,"methodology":"percent of total billed charges"},{"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":157.40,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":124.92,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":166.56,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":99.94,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":108.68,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":129.09,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":54.13,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":54.13,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":54.13,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":54.13,"methodology":"percent of total billed charges"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_percentage":28.10,"standard_charge_algorithm":"Reimbursement will be 28.1% of billable gross charges.","estimated_amount":117.01,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":26.00,"standard_charge_algorithm":"Reimbursement will be 26% of billable gross charges.","estimated_amount":108.27,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":79.12,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":112.43,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":86.20,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","estimated_amount":71.21,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":333.13,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":187.38,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":77.04,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC ","code_information":[{"code":"690","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3087.00,"maximum":14138.00,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":8378.57,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":8323.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7.  If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":11844.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7.  If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9549.00,"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) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":6641.00,"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) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14138.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7.  If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":7979.59,"methodology":"fee schedule"},{"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":7899.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":7899.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":7899.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":7899.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":7899.80,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":11570.41,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":8139.18,"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":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9028.45,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":7732.22,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":7732.22,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":8458.37,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":7979.59,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":11125.64,"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":7820.00,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":7093.38,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":8378.57,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":8139.18,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":8139.18,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":8139.18,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":8139.18,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":8139.18,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":8538.16,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":8059.39,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":7979.59,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":8777.55,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":7899.80,"methodology":"fee schedule"}]}]},{"description":"KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC ","code_information":[{"code":"651","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":48131.64,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":31159.87,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":37.90,"standard_charge_algorithm":"Reimbursement will be 37.9% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":26.00,"standard_charge_algorithm":"Reimbursement will be 26% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":24.30,"standard_charge_algorithm":"Reimbursement will be 24.3% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":32.00,"standard_charge_algorithm":"Reimbursement will be 32% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":27.30,"standard_charge_algorithm":"Reimbursement will be 27.3% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":29676.07,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per 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","code_information":[{"code":"75982","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":13787.50,"discounted_cash":13787.50,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":6135.44,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":6135.44,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":6135.44,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":4839.41,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":4839.41,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":4839.41,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":4480.94,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":4480.94,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":4480.94,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":5680.45,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":5680.45,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":5680.45,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":4150.04,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":3860.50,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":4122.46,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":4163.82,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":3695.05,"methodology":"percent of total billed charges"},{"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":5211.67,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":4136.25,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":5515.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":3309.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":3598.54,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":4274.13,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":1792.38,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":1792.38,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":1792.38,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice 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charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":3722.63,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":2854.01,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","estimated_amount":2357.66,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":11030.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":6204.38,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":2550.69,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"KIT ANCHOR SUT 4.75MM ","code_information":[{"code":"111443","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":14835.00,"discounted_cash":14835.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% 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$8633.","estimated_amount":3560.40,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":3871.93,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":4598.85,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":1928.55,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice 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charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":26.00,"standard_charge_algorithm":"Reimbursement will be 26% of billable gross charges.","estimated_amount":3857.10,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":2818.65,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":4005.45,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":3070.84,"methodology":"percent of total billed 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of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":15.89,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":16.05,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":14.24,"methodology":"percent of total billed charges"},{"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":20.09,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":15.94,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":21.26,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":12.75,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":13.87,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":16.47,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":6.91,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":6.91,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":6.91,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":6.91,"methodology":"percent of total billed charges"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_percentage":28.10,"standard_charge_algorithm":"Reimbursement will be 28.1% of billable gross charges.","estimated_amount":14.93,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":26.00,"standard_charge_algorithm":"Reimbursement will be 26% of billable gross charges.","estimated_amount":13.82,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":10.10,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":14.35,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":11.00,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","estimated_amount":9.09,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":42.51,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":23.91,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":9.83,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"MINOR BLADDER PROCEDURES WITH CC ","code_information":[{"code":"663","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":23658.20,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":14562.87,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":11693.94,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":10673.46,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":23658.20,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":13869.40,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13730.71,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13730.71,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":13730.71,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":13730.71,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":13730.71,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":20110.63,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":14146.79,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":20332.94,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":17180.60,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":13439.45,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":13439.45,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":14701.56,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":13869.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":21171.43,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":16198.54,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":13592.01,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":13498.28,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":14562.87,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":14146.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":14146.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":14146.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":14146.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":14146.79,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":14840.26,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":14008.09,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13869.40,"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":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15256.34,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13730.71,"methodology":"fee schedule"}]}]},{"description":"MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC ","code_information":[{"code":"345","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":23352.03,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":14237.74,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":11542.61,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":10535.33,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":23352.03,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":13559.75,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13424.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13424.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":13424.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":13424.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":13424.15,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":19661.64,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":13830.94,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":19825.72,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":16752.01,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":13139.40,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":13139.40,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":14373.34,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":13559.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":20643.29,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":15794.46,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":13288.56,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":13161.55,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":14237.74,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":13830.94,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":13830.94,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":13830.94,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":13830.94,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":13830.94,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":14508.93,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":13695.35,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13559.75,"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":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":14915.73,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13424.15,"methodology":"fee schedule"}]}]},{"description":"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOU ","code_information":[{"code":"641","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":12495.00,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":8198.51,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":6338.30,"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) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":5599.18,"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) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10884.61,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":7808.11,"methodology":"fee schedule"},{"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":7730.03,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":7730.03,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":7730.03,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":7730.03,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":7730.03,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":11321.76,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":7964.27,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":10404.11,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":8791.09,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":7566.06,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":7566.06,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":8276.59,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":7808.11,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":10833.15,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":8288.59,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":7651.94,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":6906.90,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":8198.51,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":7964.27,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":7964.27,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":7964.27,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":7964.27,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":7964.27,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":8354.67,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":7886.19,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":7808.11,"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":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":8588.92,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":7730.03,"methodology":"fee schedule"}]}]},{"description":"MIXER CEMENT 80GR DBL ","code_information":[{"code":"607025","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":6218.00,"discounted_cash":6218.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":2767.01,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross 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charges.","estimated_amount":2561.82,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":2561.82,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":2561.82,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":1871.62,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross 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charges.","estimated_amount":2350.40,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":1865.40,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":2487.20,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":1492.32,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross 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charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":1181.42,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":1678.86,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":1287.13,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","estimated_amount":1063.28,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":4974.40,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":2798.10,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":1150.33,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"MODAFINIL 100MG TAB ","code_information":[{"code":"810123","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":300.11,"discounted_cash":300.11,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":133.55,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":133.55,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":133.55,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":105.34,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":105.34,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":105.34,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":97.54,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":97.54,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":97.54,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":123.65,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":123.65,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":123.65,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":90.33,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":84.03,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":89.73,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":90.63,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":80.43,"methodology":"percent of total billed charges"},{"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":113.44,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":90.03,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":120.04,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":72.03,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":78.33,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":93.03,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":39.01,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":39.01,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":39.01,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross 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MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":2879.31,"methodology":"percent of total billed charges"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_percentage":28.10,"standard_charge_algorithm":"Reimbursement will be 28.1% of billable gross charges.","estimated_amount":6223.75,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":4208.23,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":5980.11,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":17718.86,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":9966.86,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":4097.49,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"Mucoprotein, blood (seromucoid) (medical necessity procedure) ","code_information":[{"code":"P2038","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4.85,"maximum":30.94,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":30.94,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":30.94,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":30.94,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":24.36,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":24.36,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":24.36,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":22.60,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":22.60,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":22.60,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":28.61,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":28.61,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":28.61,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":5.20,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":20.29,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":15.49,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.95,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":17.23,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16.04,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":4.95,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":5.36,"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":4.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":4.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":4.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":4.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":4.95,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":7.18,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":4.95,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":4.95,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":4.95,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":5.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":10.15,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":13.61,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":4.85,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":13.61,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":5.20,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":5.25,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":5.25,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":5.25,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":5.25,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":5.25,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":5.20,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":4.95,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":6.44,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":4.97,"methodology":"fee schedule"}]}]},{"description":"MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC ","code_information":[{"code":"059","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":16960.16,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":11970.37,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":9473.83,"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) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":8369.08,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16269.19,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":11400.35,"methodology":"fee schedule"},{"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":11286.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":11286.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":11286.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":11286.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":11286.35,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":16530.51,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":11628.36,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":16288.46,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":13763.15,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":11046.94,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":11046.94,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":12084.37,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":11400.35,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":16960.16,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":12976.44,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":11172.34,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":10813.29,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":11970.37,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":11628.36,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":11628.36,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":11628.36,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":11628.36,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":11628.36,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":12198.37,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":11514.35,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":11400.35,"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":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":12540.39,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":11286.35,"methodology":"fee schedule"}]}]},{"description":"MUPIROCIN TOPICAL ","code_information":[{"code":"150143","type":"CDM"},{"code":"S5000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":23.63,"discounted_cash":23.63,"payers_information":[{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":7.11,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":6.62,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":7.07,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":7.14,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":6.33,"methodology":"percent of total billed charges"},{"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":8.93,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":7.09,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":9.45,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":3.07,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":3.07,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":3.07,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":3.07,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":6.38,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":18.90,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":10.63,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":4.37,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. ","code_information":[{"code":"826","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":66193.82,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":42279.15,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 9. "},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"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":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":40265.86,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":39863.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":39863.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":39863.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":39863.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":39863.20,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":58385.50,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":41071.18,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":63572.24,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":53716.22,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":39017.62,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":39017.62,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":42681.81,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":40265.86,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":66193.82,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":50645.77,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":39460.54,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":42203.22,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":42279.15,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 9. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":41071.18,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":41071.18,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":41071.18,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":41071.18,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":41071.18,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":43084.47,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":40668.52,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":40265.86,"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":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":44292.45,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":39863.20,"methodology":"fee schedule"}]}]},{"description":"NACL 0.9% IRRIG SOL 1L ","code_information":[{"code":"415645","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":87.60,"discounted_cash":87.60,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":38.98,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross 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charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":27000.00,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":20700.00,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","estimated_amount":17100.00,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":80000.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":45000.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":18500.00,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"DVC SKN CLSR 8CM ","code_information":[{"code":"630166","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":2880.00,"discounted_cash":2880.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of 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charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":26.00,"standard_charge_algorithm":"Reimbursement will be 26% of billable gross charges.","estimated_amount":748.80,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":547.20,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":777.60,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":596.16,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","estimated_amount":492.48,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":2304.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":1296.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":532.80,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"Dynamic adjustable elbow extension and flexion device, includes soft interface material ","code_information":[{"code":"E1800","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":142.06,"maximum":297.17,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":152.21,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":144.96,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":144.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":144.96,"methodology":"fee schedule"},{"payer_name":"Cigna 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IPA","plan_name":"MCR","standard_charge_dollar":149.31,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":297.17,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":142.06,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":152.21,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":153.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":153.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":153.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":153.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":153.66,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":152.21,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":144.96,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":188.45,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":145.68,"methodology":"fee schedule"}]}]},{"description":"DYSEQUILIBRIUM ","code_information":[{"code":"149","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":12495.00,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":7908.37,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":6193.75,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":5471.49,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10636.38,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":7531.78,"methodology":"fee schedule"},{"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":7456.46,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":7456.46,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":7456.46,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":7456.46,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":7456.46,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":10921.08,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":7682.42,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":9951.47,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":8408.63,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":7298.30,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":7298.30,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7983.69,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":7531.78,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":10361.85,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":7927.99,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":7381.15,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":6606.41,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":7908.37,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":7682.42,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":7682.42,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":7682.42,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":7682.42,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":7682.42,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":8059.01,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":7607.10,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":7531.78,"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":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":8284.96,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":7456.46,"methodology":"fee schedule"}]}]},{"description":"Echo guidance radiotherap ","code_information":[{"code":"4001","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":137.71,"maximum":288.07,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":147.55,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":140.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":140.52,"methodology":"fee schedule"},{"payer_name":"Cigna 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charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":148.77,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":176.70,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":74.10,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":74.10,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":74.10,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":74.10,"methodology":"percent of total billed charges"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_percentage":28.10,"standard_charge_algorithm":"Reimbursement will be 28.1% of billable gross charges.","estimated_amount":160.17,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":26.00,"standard_charge_algorithm":"Reimbursement will be 26% of billable gross charges.","estimated_amount":148.20,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":108.30,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":153.90,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":117.99,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","estimated_amount":97.47,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":456.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":256.50,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":105.45,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT ","code_information":[{"code":"927","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9330.00,"maximum":328845.45,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":203970.38,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 24. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":37.90,"standard_charge_algorithm":"Reimbursement will be 37.9% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":37.20,"standard_charge_algorithm":"Reimbursement will be 37.2% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":32.00,"standard_charge_algorithm":"Reimbursement will be 32% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":43.50,"standard_charge_algorithm":"Reimbursement will be 43.5% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":194257.50,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":17.40,"standard_charge_algorithm":"Reimbursement will be 17.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":18.90,"standard_charge_algorithm":"Reimbursement will be 18.9% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":192314.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":192314.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":192314.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":192314.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":192314.92,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":281673.38,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":198142.65,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_percentage":46.80,"standard_charge_algorithm":"Reimbursement will be 46.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":266857.78,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":188235.52,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":188235.52,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":205912.95,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":194257.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":328845.45,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":27.70,"standard_charge_algorithm":"Reimbursement will be 27.7% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":190372.35,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":23.10,"standard_charge_algorithm":"Reimbursement will be 23.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":203970.38,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 24. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":198142.65,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":198142.65,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":198142.65,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":198142.65,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":198142.65,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":207855.53,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":196200.08,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":194257.50,"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":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":213683.25,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":192314.92,"methodology":"fee schedule"}]}]},{"description":"External lower extremity nerve stimulator for restless legs syndrome, each ","code_information":[{"code":"E0743","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":227.24,"maximum":475.35,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":243.47,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":231.88,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":231.88,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":231.88,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":231.88,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":231.88,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":231.88,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":231.88,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":336.23,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":231.88,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":231.88,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":231.88,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":238.84,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":475.35,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":227.24,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":243.47,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":245.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":245.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":245.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":245.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":245.79,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":243.47,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":231.88,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":301.44,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":233.04,"methodology":"fee schedule"}]}]},{"description":"EXTRACRANIAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"039","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":16848.43,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":11242.44,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":8327.96,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":7601.21,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16848.43,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":10707.09,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":10600.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":10600.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":10600.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":10600.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":10600.02,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":15525.28,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":10921.23,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":15152.86,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":12803.61,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":10375.17,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":10375.17,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":11349.52,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":10707.09,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":15777.73,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":12071.75,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":10492.95,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":10059.41,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":11242.44,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":10921.23,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":10921.23,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":10921.23,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":10921.23,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":10921.23,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":11456.59,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":10814.16,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":10707.09,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12044.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":7842.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11400.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9185.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":11777.80,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":10600.02,"methodology":"fee schedule"}]}]},{"description":"EXTRAOCULAR PROCEDURES EXCEPT ORBIT ","code_information":[{"code":"115","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":21544.57,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":14593.59,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":10649.20,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":9719.89,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":21544.57,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":13898.66,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13759.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13759.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":13759.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":13759.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":13759.67,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":20153.06,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":14176.63,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":20380.87,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":17221.09,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":13467.80,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":13467.80,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":14732.58,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":13898.66,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":21221.34,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":16236.73,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":13620.69,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":13530.09,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":14593.59,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":14176.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":14176.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":14176.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":14176.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":14176.63,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":14871.57,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":14037.65,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13898.66,"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":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15288.53,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13759.67,"methodology":"fee schedule"}]}]},{"description":"Face tent ","code_information":[{"code":"A4619","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":2.38,"maximum":4.98,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":2.55,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":2.43,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":2.43,"methodology":"fee schedule"},{"payer_name":"Cigna 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Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":1.77,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":1.77,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":1.77,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":1.76,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":1.67,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":2.18,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":1.68,"methodology":"fee schedule"}]}]},{"description":"Factor viii recomb novoei ","code_information":[{"code":"1856","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1.35,"maximum":2.82,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":1.45,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":1.38,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1.38,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":1.38,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":1.38,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":1.38,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":1.38,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":2.00,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":1.38,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":1.38,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":1.38,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":1.42,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":2.82,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":1.35,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":1.45,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":1.46,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":1.46,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":1.46,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":1.46,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":1.46,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":1.45,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":1.38,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":1.79,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":1.38,"methodology":"fee schedule"}]}]},{"description":"FAMOTIDINE 20 MG TAB ","code_information":[{"code":"805020","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":60.98,"discounted_cash":60.98,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":27.14,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":27.14,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross 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total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":18.42,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":16.34,"methodology":"percent of total billed charges"},{"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":23.05,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":18.29,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":24.39,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":14.64,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":15.92,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":18.90,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":7.93,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":7.93,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":7.93,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross 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(nonalcoholic fatty liver disease), semiquantitative evaluation of 28 lipid markers by liquid chromatography with tandem mass spectometry, serum, reported as at-risk for nonalcoholic steato ","code_information":[{"code":"0344U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":77.46,"maximum":2178.47,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":831.78,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":105.16,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":80.28,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":77.46,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":89.26,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":83.11,"methodology":"fee schedule"},{"payer_name":"CHC Harris 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":9944.42,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":9076.61,"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) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20118.72,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":12291.09,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":12168.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":12168.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":12168.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":12168.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":12168.18,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":17822.08,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":12536.91,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":17747.56,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":14996.04,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":11910.07,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":11910.07,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":13028.56,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":12291.09,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":18479.43,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":14138.86,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":12045.27,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":11781.94,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":12905.64,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":12536.91,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":12536.91,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":12536.91,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":12536.91,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":12536.91,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13151.47,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":12414.00,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":12291.09,"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":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":13520.20,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":12168.18,"methodology":"fee schedule"}]}]},{"description":"High strength lightweight wheelchair, fixed full length arms, swing away detachable elevating leg rests ","code_information":[{"code":"E1087","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":169.20,"maximum":353.93,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":181.28,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":172.65,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":172.65,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":172.65,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":172.65,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":172.65,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":172.65,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":172.65,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":250.34,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":172.65,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":172.65,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":172.65,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":177.83,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":353.93,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":169.20,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":181.28,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":183.01,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":183.01,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":183.01,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":183.01,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":183.01,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":181.28,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":172.65,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":224.45,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":173.51,"methodology":"fee schedule"}]}]},{"description":"HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC ","code_information":[{"code":"481","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13801.00,"maximum":34044.86,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":19235.87,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":34044.86,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $332319.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $12398 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":29575.97,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $456984.00, reimbursement will be the lesser of (a) 26% of billable gross charges, or (b) $20042 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":28383.29,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $18386 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":25308.31,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $282471.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $11523 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":30766.56,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $472742.00, reimbursement will be the lesser of (a) 27.3% of billable gross charges, or (b) $21697 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":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":18319.88,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":17812.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":19294.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22948.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":18136.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":18136.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":18136.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":18136.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":18136.68,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":26563.83,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":18686.28,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":27623.14,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":23340.55,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":17751.96,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":17751.96,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":19419.07,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":18319.88,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":28762.26,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":22006.39,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":17953.48,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":18337.97,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":19235.87,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":18686.28,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":18686.28,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":18686.28,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":18686.28,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":18686.28,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":21983.86,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":18503.08,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":18319.88,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":18596.00,"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":"NarrowNetworkIndivExchange","standard_charge_dollar":13801.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":17601.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":15653.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":21983.86,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":18136.68,"methodology":"fee schedule"}]}]},{"description":"Hip knee ankle foot orthosis, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated ","code_information":[{"code":"L2050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":609.25,"maximum":1274.44,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":652.76,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":621.68,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":621.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":621.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":621.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":621.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":621.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":621.68,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":901.44,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":621.68,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":621.68,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":621.68,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":640.33,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":1274.44,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":609.25,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":652.76,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":658.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":658.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":658.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":658.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":658.98,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":652.76,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":621.68,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":808.18,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":624.79,"methodology":"fee schedule"}]}]},{"description":"Hip orthosis, abduction control of hip joints, flexible, (pavlik harness), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an in ","code_information":[{"code":"L1620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":144.45,"maximum":302.17,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":154.77,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":147.40,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":147.40,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":147.40,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":147.40,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":147.40,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":147.40,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":147.40,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":213.73,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":147.40,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":147.40,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":147.40,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":151.82,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":302.17,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":144.45,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":154.77,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":156.24,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":156.24,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":156.24,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":156.24,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":156.24,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":154.77,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":147.40,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":191.62,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":148.14,"methodology":"fee schedule"}]}]},{"description":"Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, off the shelf ","code_information":[{"code":"L1653","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":413.25,"maximum":864.44,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":442.76,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":421.68,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":421.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":421.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":421.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":421.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":421.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":421.68,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":611.44,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":421.68,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":421.68,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":421.68,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":434.33,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":864.44,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":413.25,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":442.76,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":446.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":446.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":446.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":446.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":446.98,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":442.76,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":421.68,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":548.18,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":423.79,"methodology":"fee schedule"}]}]},{"description":"HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC ","code_information":[{"code":"970","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":44205.86,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":24170.85,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":21850.39,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":19943.60,"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) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":44205.86,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":23019.86,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":22789.66,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":22789.66,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":22789.66,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":22789.66,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":22789.66,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":33378.80,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":23480.26,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":35322.05,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":29845.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":22306.24,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":22306.24,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":24401.05,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":23019.86,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":36778.66,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":28139.84,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":22559.46,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":23448.98,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":24170.85,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":23480.26,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":23480.26,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":23480.26,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":23480.26,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":23480.26,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":24631.25,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":23250.06,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":23019.86,"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":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":25321.85,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":22789.66,"methodology":"fee schedule"}]}]},{"description":"HNDPC STRL DISP 10FTCRD ","code_information":[{"code":"606500","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":2880.00,"discounted_cash":2880.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":1281.60,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":1281.60,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":1281.60,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":1010.88,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":1010.88,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":1010.88,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":936.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":936.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":936.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross 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charges.","estimated_amount":806.40,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":861.12,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":869.76,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":771.84,"methodology":"percent of total billed charges"},{"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":1088.64,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":864.00,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":1152.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":691.20,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross 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MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":374.40,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":374.40,"methodology":"percent of total billed charges"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_percentage":28.10,"standard_charge_algorithm":"Reimbursement will be 28.1% of billable gross charges.","estimated_amount":809.28,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":26.00,"standard_charge_algorithm":"Reimbursement will be 26% of billable gross charges.","estimated_amount":748.80,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":547.20,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":777.60,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":596.16,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","estimated_amount":492.48,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":2304.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":1296.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":532.80,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"HOLDERTRACH TUBE DALE 2 ","code_information":[{"code":"73654","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":68.00,"discounted_cash":68.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":30.26,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":30.26,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":30.26,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":23.87,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":23.87,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":23.87,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":22.10,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":22.10,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":22.10,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":28.02,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":28.02,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":28.02,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":20.47,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":19.04,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":20.33,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":20.54,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":18.22,"methodology":"percent of total billed charges"},{"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":25.70,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":20.40,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":27.20,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":16.32,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":17.75,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":21.08,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":8.84,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":8.84,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":8.84,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":6124.84,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":5410.61,"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) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10518.04,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":6875.10,"methodology":"fee schedule"},{"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":6806.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":6806.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":6806.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":6806.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":6806.35,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":9968.90,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":7012.60,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":8875.78,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":7499.71,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":6661.97,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":6661.97,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7287.61,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":6875.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":9241.80,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":7071.02,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":6737.60,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":5892.29,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":7218.86,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":7012.60,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":7012.60,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":7012.60,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":7012.60,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":7012.60,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":7356.36,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":6943.85,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":6875.10,"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":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":7562.61,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6806.35,"methodology":"fee schedule"}]}]},{"description":"I131 iodide cap, rx ","code_information":[{"code":"1064","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":20.91,"maximum":43.75,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":22.41,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":21.34,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":21.34,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":21.34,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":21.34,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":21.34,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":21.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":30.94,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":21.34,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":21.34,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":21.34,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":21.98,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":43.75,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":20.91,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":22.41,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":22.62,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":22.62,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":22.62,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":22.62,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":22.62,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":22.41,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":21.34,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":27.74,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":21.45,"methodology":"fee schedule"}]}]},{"description":"Idursulfase injection ","code_information":[{"code":"9045","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":527.17,"maximum":1102.75,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":564.82,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":537.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":537.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":537.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":537.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":537.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":537.92,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":779.99,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":537.92,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":537.92,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":537.92,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":554.06,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":1102.75,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":527.17,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":564.82,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":570.20,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":570.20,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":570.20,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":570.20,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":570.20,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":564.82,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":537.92,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":699.30,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":540.61,"methodology":"fee schedule"}]}]},{"description":"IMATINIB 100 MG PO ","code_information":[{"code":"807284","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":1121.44,"discounted_cash":1121.44,"payers_information":[{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":337.55,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":314.00,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":335.31,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":338.67,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":300.55,"methodology":"percent of total billed charges"},{"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":423.90,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":336.43,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":448.58,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":145.79,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":145.79,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":145.79,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":145.79,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":302.79,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":897.15,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":504.65,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":207.47,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"Immediate post surgical or early fitting, application of initial rigid dressing, incl. fitting, alignment and supension, 'ak' or knee disarticulation, each additional cast change and realignment ","code_information":[{"code":"L5430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":770.71,"maximum":1612.20,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":825.76,"methodology":"fee schedule"},{"payer_name":"CHC Harris 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Health","plan_name":"MGMCR","standard_charge_dollar":786.44,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":786.44,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":786.44,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":810.03,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":1612.20,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":770.71,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":825.76,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":833.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":833.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":833.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":833.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":833.63,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":825.76,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":786.44,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":1022.37,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":790.37,"methodology":"fee schedule"}]}]},{"description":"Immediate post surgical or early fitting, each additional cast change and realignment ","code_information":[{"code":"L6386","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":513.51,"maximum":1074.18,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":550.19,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":523.99,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":523.99,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":523.99,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":523.99,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":523.99,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":523.99,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":523.99,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":759.79,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":523.99,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":523.99,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":523.99,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":539.71,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":1074.18,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":513.51,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":550.19,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":555.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":555.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":555.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":555.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":555.43,"methodology":"fee schedule"},{"payer_name":"Shared 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Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":414.91,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":410.99,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":391.42,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":508.85,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":393.38,"methodology":"fee schedule"}]}]},{"description":"Indwelling catheter, foley type, two-way, all silicone or polyurethane, each ","code_information":[{"code":"A4344","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":18.19,"maximum":38.05,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":19.49,"methodology":"fee 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":8149.36,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":7199.05,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13994.71,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":9740.76,"methodology":"fee schedule"},{"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":9643.36,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":9643.36,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":9643.36,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":9643.36,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":9643.36,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":14124.11,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":9935.58,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":13569.94,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":11466.11,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":9438.80,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":9438.80,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":10325.21,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":9740.76,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":14129.54,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":10810.70,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":9545.95,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":9008.57,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":10227.80,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":9935.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":9935.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":9935.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":9935.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":9935.58,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":10422.62,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":9838.17,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":9740.76,"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":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":10714.84,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":9643.36,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA), Bartonella henselae and Bartonella quintana, droplet digital PCR (ddPCR); ","code_information":[{"code":"0301U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":105.97,"maximum":722.48,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":275.86,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":143.87,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":109.83,"methodology":"fee 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charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":34.53,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":34.53,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":43.78,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":43.78,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":43.78,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":31.98,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":29.75,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":31.77,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":32.09,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":28.48,"methodology":"percent of total billed charges"},{"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":40.17,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":31.88,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":42.50,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":25.50,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":27.73,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":32.94,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":13.81,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":13.81,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":13.81,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":13.81,"methodology":"percent of total billed charges"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_percentage":28.10,"standard_charge_algorithm":"Reimbursement will be 28.1% of billable gross charges.","estimated_amount":29.86,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":26.00,"standard_charge_algorithm":"Reimbursement will be 26% of billable gross charges.","estimated_amount":27.63,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":20.19,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":28.69,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":22.00,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","estimated_amount":18.17,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":85.01,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":47.82,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":19.66,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC ","code_information":[{"code":"659","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":48318.00,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":23582.03,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":19494.05,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":17792.89,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":39438.72,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":22459.08,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":22234.49,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":22234.49,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":22234.49,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":22234.49,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":22234.49,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":32565.67,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":22908.26,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":34403.45,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":29069.67,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":21762.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":21762.85,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":23806.62,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":22459.08,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":35822.18,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":27408.03,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":22009.90,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":22839.16,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":23582.03,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":22908.26,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":22908.26,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":22908.26,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":22908.26,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":22908.26,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":24031.22,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":22683.67,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":22459.08,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":48318.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 8. "},{"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":"NarrowNetworkIndivExchange","standard_charge_dollar":35859.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 8. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":45733.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 8. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":33028.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 8. "},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":24704.99,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":22234.49,"methodology":"fee schedule"}]}]},{"description":"KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC ","code_information":[{"code":"696","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":12495.00,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":7432.20,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":5814.73,"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) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12495.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10558.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":5136.67,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9985.50,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":7078.28,"methodology":"fee schedule"},{"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":7007.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":7007.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":7007.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":7007.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":7007.50,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":10263.51,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":7219.85,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":9208.60,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":7780.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":6858.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":6858.85,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7502.98,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":7078.28,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":9588.35,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":7336.17,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":6936.72,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":6113.24,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":7432.20,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":7219.85,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":7219.85,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":7219.85,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":7219.85,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":7219.85,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":7573.76,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":7149.06,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":7078.28,"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":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":7786.11,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":7007.50,"methodology":"fee schedule"}]}]},{"description":"KIT ACC COMP STYLET DIL ","code_information":[{"code":"100042","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":17453.00,"discounted_cash":17453.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":7766.59,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":7766.59,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":7766.59,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":6126.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":6126.00,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross 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charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":116.46,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":116.46,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":91.86,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":91.86,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":91.86,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":85.05,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":85.05,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":85.05,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":107.82,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":107.82,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":107.82,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":78.77,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":73.28,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":78.25,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":79.03,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":70.14,"methodology":"percent of total billed charges"},{"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":98.92,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":78.51,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":104.68,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":62.81,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":68.30,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":81.13,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":34.02,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross 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26% of billable gross charges.","estimated_amount":68.04,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":49.72,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":70.66,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":54.17,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross 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C.D.E. WITH MCC ","code_information":[{"code":"417","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":35857.82,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":21809.60,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":17724.06,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 20.7% of billable gross charges, or (b) $5498 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12412.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $503561.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10033.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $441225.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":16177.35,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 17.5% of billable gross charges, or (b) $4936 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":35857.82,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $565896.00, reimbursement will be the lesser of (a) 25.9% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":20771.05,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":20563.34,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":20563.34,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":20563.34,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":20563.34,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":20563.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":30118.02,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":21186.47,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":31638.34,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":26733.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":20127.15,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":20127.15,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":22017.31,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":20771.05,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":32943.04,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":25205.16,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":20355.63,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":21003.51,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":21809.60,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":21186.47,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":21186.47,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":21186.47,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":21186.47,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":21186.47,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":22225.02,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":20978.76,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":20771.05,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":22848.16,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":20563.34,"methodology":"fee schedule"}]}]},{"description":"Laronidase injection ","code_information":[{"code":"9209","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":37.92,"maximum":79.33,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":40.63,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":38.70,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":38.70,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":38.70,"methodology":"fee 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Healthcare","plan_name":"HIX","standard_charge_dollar":79.33,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":37.92,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":40.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":41.02,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":41.02,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":41.02,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":41.02,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":41.02,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":40.63,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":38.70,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":50.31,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":38.89,"methodology":"fee schedule"}]}]},{"description":"LD PERM IMPLT PACING ","code_information":[{"code":"104136","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":14735.00,"discounted_cash":14735.00,"payers_information":[{"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":5569.83,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_percentage":30.00,"standard_charge_algorithm":"Reimbursement will be 30% of billable gross charges.","estimated_amount":4420.50,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":5894.00,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":1915.55,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":1915.55,"methodology":"percent of total billed 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