{"hospital_name":"HCA HOUSTON HEALTHCARE TOMBALL","last_updated_on":"2024-10-01","version":"2.2.0","affirmation":{"affirmation":"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.","confirm_affirmation":true},"hospital_location":["HCA HOUSTON HEALTHCARE TOMBALL","HCA HOUSTON ER 24/7 - CYPRESS/FM 1960"],"hospital_address":["605 Holderrieth Blvd, Tomball, TX, 77375","5003 CYPRESS CREEK PKWY, HOUSTON, TX, 77069"],"license_information":{"hospital_license_number":"100409","state":"TX"},"standard_charge_information":[{"description":"ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC ","code_information":[{"code":"614","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":33498.81,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":18495.74,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":19676.32,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":19968.33,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13099.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12180.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":18739.35,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":18739.35,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":18326.61,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":33498.81,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":18739.35,"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":18551.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":18551.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":18551.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":18551.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":18551.96,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":27172.06,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":19114.14,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":30337.66,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":25634.22,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":33430.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":18158.43,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":18158.43,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":33430.00,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":19863.71,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":18739.35,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":26047.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":31297.04,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":24168.95,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":18364.56,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":20140.03,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":19676.32,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":19114.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":19114.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":19114.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":19114.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":19114.14,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":20051.10,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":29045.99,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":29045.99,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":29045.99,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":19676.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":19676.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":19676.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":19676.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":19676.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":19676.32,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":18926.74,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":18739.35,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":18289.61,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":18926.74,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":20613.28,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":18926.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":18926.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":18926.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":18926.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":18926.74,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":18551.96,"methodology":"fee schedule"}]}]},{"description":"Afamelanotide implant, 1 ","code_information":[{"code":"9396","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":2815.86,"maximum":5890.32,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":2897.75,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":3017.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":2873.33,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":2873.33,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":2873.33,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":2873.33,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":2873.33,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":2873.33,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":2873.33,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":2873.33,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":4166.33,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":2873.33,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":2873.33,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":2873.33,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":2959.53,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":3993.93,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":5890.32,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":2815.86,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":3017.00,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":3045.73,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":3045.73,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":3045.73,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":3045.73,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":3045.73,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":3017.00,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":4453.66,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":4453.66,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":4166.33,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":3017.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":3017.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":3017.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":3017.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":3017.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":3017.00,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":2873.33,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":2887.70,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":2902.06,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":3735.33,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":2959.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":2959.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":2959.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":2959.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":2959.53,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":2887.70,"methodology":"fee schedule"}]}]},{"description":"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC ","code_information":[{"code":"559","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":27228.99,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":15433.25,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":16418.35,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":18362.01,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":15636.52,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":15636.52,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":16388.53,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":24965.18,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":15636.52,"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":15480.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":15480.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":15480.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":15480.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":15480.15,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":22672.95,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":15949.25,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":24710.26,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":20879.27,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":27228.99,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":15151.79,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":15151.79,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":27228.99,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":16574.71,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":15636.52,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":21734.76,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":25491.68,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":19685.80,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":15323.79,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":16404.21,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":16418.35,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":15949.25,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":15949.25,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":15949.25,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":15949.25,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":15949.25,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":16731.08,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":24236.61,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":24236.61,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":24236.61,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":16418.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":16418.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":16418.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":16418.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":16418.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":16418.35,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":15792.89,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":15636.52,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":15261.24,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":15792.89,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":17200.17,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":15792.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":15792.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":15792.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":15792.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":15792.89,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":15480.15,"methodology":"fee 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schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":18.79,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":21.04,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":5.78,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":5.78,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":9.88,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16.53,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":5.78,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":6.26,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":26.97,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":29.26,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":34.79,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":5.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":5.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":5.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":5.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":5.78,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":8.38,"methodology":"fee schedule"},{"payer_name":"Community Health Choice 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schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":5.78,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":6.07,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":5.95,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":8.03,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":4.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":11.85,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":4.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":4.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":4.40,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":15.90,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":5.66,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":15.90,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":6.07,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":6.13,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":6.13,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":6.13,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":6.13,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":6.13,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":6.07,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":8.96,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":8.96,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":8.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":6.07,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":6.07,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":6.07,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":6.07,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":6.07,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":6.07,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":4.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":4.00,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":5.78,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":5.81,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":5.84,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":7.51,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":5.95,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":5.95,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":5.95,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":5.95,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":5.95,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":5.81,"methodology":"fee schedule"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY  IPF","code_information":[{"code":"895","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":993.55,"maximum":1063.80,"payers_information":[{"payer_name":"American Health 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"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":993.55,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":993.55,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":993.55,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":993.55,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":993.55,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":1003.59,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":1003.59,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":1063.80,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":1003.59,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":1023.66,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":1023.66,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":1023.66,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":1023.66,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":1023.66,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":1003.59,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":1003.59,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":1003.59,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":1003.59,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":1003.59,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":1003.59,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":1003.59,"methodology":"fee schedule","additional_payer_notes":"Days 3. "}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC  IPF","code_information":[{"code":"896","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":995.00,"maximum":15837.97,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":15837.97,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1478.32,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":1478.32,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":1478.32,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":1478.32,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":1478.32,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":1493.26,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":1493.26,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":1582.85,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":1493.26,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":995.00,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":1523.12,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":1523.12,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":1523.12,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":1523.12,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":1523.12,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":1493.26,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":1493.26,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4767.00,"methodology":"per diem","additional_payer_notes":"Days 3+.  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":"NarrowNetworkIndivExchange","standard_charge_dollar":3105.00,"methodology":"per diem","additional_payer_notes":"Days 3+.  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":4564.00,"methodology":"per diem","additional_payer_notes":"Days 3+.  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":"SmallGroup","standard_charge_dollar":3056.00,"methodology":"per diem","additional_payer_notes":"Days 3+.  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If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":27988.77,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":30482.82,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":27988.77,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":27988.77,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":27988.77,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":27988.77,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":27988.77,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":27434.53,"methodology":"fee 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Healthcare","plan_name":"HIX","standard_charge_dollar":16563.20,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":12790.84,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":10647.17,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":10658.63,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":11407.68,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":11081.75,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":11081.75,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":11081.75,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":11081.75,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":11081.75,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":11624.97,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":16839.91,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":16839.91,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":16839.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":11407.68,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":11407.68,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":11407.68,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":11407.68,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":11407.68,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":11407.68,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":10973.10,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":10864.46,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":10603.71,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":10973.10,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":11950.91,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":10973.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":10973.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":10973.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":10973.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":10973.10,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":10755.82,"methodology":"fee 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schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":1983.60,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3317.60,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":1740.00,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":8149.78,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":8844.08,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":10513.72,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1740.00,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":1740.00,"methodology":"fee schedule"},{"payer_name":"Cigna 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schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":2418.60,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":3567.00,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":4785.00,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":1705.20,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":4785.00,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":1827.00,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":1844.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":1844.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":1844.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":1844.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":1844.40,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":1827.00,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":2697.00,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":2697.00,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":2523.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":1827.00,"methodology":"fee schedule"},{"payer_name":"Superior Health 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Plan","plan_name":"MCR","standard_charge_dollar":2262.00,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":1792.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":1792.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":1792.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":1792.20,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":1792.20,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":1748.70,"methodology":"fee schedule"}]}]},{"description":"CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC ","code_information":[{"code":"323","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":62482.46,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":20295.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":20295.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":20295.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":15968.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":15968.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":15968.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":32843.89,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":14816.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":14816.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":14816.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":18785.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":18785.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":18785.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":34940.30,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13099.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12180.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":33276.48,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":33276.48,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":33276.48,"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":32943.72,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":32943.72,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":32943.72,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":32943.72,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":32943.72,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":48250.90,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":33942.01,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":56702.73,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":47911.74,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":62482.46,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":32244.91,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":32244.91,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":62482.46,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":35273.07,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":33276.48,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":46254.31,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":58495.85,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":45173.08,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":32610.95,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":37642.81,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":34940.30,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":33942.01,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":33942.01,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":33942.01,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":33942.01,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":33942.01,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":35605.83,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":51578.54,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":51578.54,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":51578.54,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":34940.30,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":34940.30,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":34940.30,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":34940.30,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":34940.30,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":34940.30,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":33609.24,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":33276.48,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":32477.84,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  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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":11809.18,"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":11691.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":11691.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":11691.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":11691.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":11691.09,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":17123.31,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":12045.36,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":17768.86,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":15014.04,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":19580.05,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":11443.10,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":11443.10,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":19580.05,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":12517.73,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":11809.18,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":16414.76,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":18330.77,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":14155.83,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":11573.00,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":11796.08,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":12399.64,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":12045.36,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":12045.36,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":12045.36,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":12045.36,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":12045.36,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":12635.82,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":18304.23,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":18304.23,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":18304.23,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":12399.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":12399.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":12399.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":12399.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":12399.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":12399.64,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":11927.27,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":11809.18,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11525.76,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":11927.27,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":12990.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":11927.27,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":11927.27,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":11927.27,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":11927.27,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":11927.27,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":11691.09,"methodology":"fee schedule"}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC  IPF","code_information":[{"code":"057","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1097.51,"maximum":1197.93,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":1197.93,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1097.51,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":1097.51,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":1097.51,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":1097.51,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":1097.51,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":1108.60,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":1108.60,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":1175.11,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":1108.60,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":1130.77,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":1130.77,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":1130.77,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":1130.77,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":1130.77,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":1108.60,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":1108.60,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":1108.60,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":1108.60,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":1108.60,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":1108.60,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":1108.60,"methodology":"fee schedule","additional_payer_notes":"Days 7. "}]}]},{"description":"DENTAL AND ORAL DISEASES WITHOUT CC/MCC ","code_information":[{"code":"159","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":12300.00,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":6764.51,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":7196.29,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":6527.56,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":6853.61,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":6853.61,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":5826.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8874.93,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":6853.61,"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":6785.07,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":6785.07,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":6785.07,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":6785.07,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":6785.07,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":9937.73,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":6990.68,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":8781.25,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":7419.84,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":9676.33,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":6641.14,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":6641.14,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":9676.33,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7264.82,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":6853.61,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":9526.51,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":9058.95,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":6995.72,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":6716.53,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":5829.54,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":7196.29,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":6990.68,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":6990.68,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":6990.68,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":6990.68,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":6990.68,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":7333.36,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":10623.09,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":10623.09,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":10623.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":7196.29,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":7196.29,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":7196.29,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":7196.29,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":7196.29,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":7196.29,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":6922.14,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":6853.61,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":6689.12,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":6922.14,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":7538.97,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":6922.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":6922.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":6922.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":6922.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":6922.14,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6785.07,"methodology":"fee schedule"}]}]},{"description":"DEPRESSIVE NEUROSES  IPF","code_information":[{"code":"881","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":995.00,"maximum":9157.85,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":9157.85,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1567.02,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":1567.02,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":1567.02,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":1567.02,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":1567.02,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":1582.85,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":1582.85,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":1677.82,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":1582.85,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":995.00,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":1614.51,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":1614.51,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":1614.51,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":1614.51,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":1614.51,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":1582.85,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":1582.85,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4767.00,"methodology":"per diem","additional_payer_notes":"Days 3+.  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":"NarrowNetworkIndivExchange","standard_charge_dollar":3105.00,"methodology":"per diem","additional_payer_notes":"Days 3+.  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":4564.00,"methodology":"per diem","additional_payer_notes":"Days 3+.  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":"SmallGroup","standard_charge_dollar":3056.00,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":1582.85,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":1582.85,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":1582.85,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":1582.85,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":1582.85,"methodology":"fee schedule","additional_payer_notes":"Days 1. 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Texas","plan_name":"PFFS","standard_charge_dollar":14.08,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":14.08,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":14.08,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":14.08,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13.94,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":20.58,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":20.58,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":19.26,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":13.94,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":13.94,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":13.94,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":13.94,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":13.94,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":13.94,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":11.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":11.00,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13.28,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13.35,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":13.41,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":17.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":13.68,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":13.68,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":13.68,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":13.68,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":13.68,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13.35,"methodology":"fee schedule"}]}]},{"description":"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC ","code_information":[{"code":"439","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":12905.47,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":8217.87,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":8742.42,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":8320.15,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":8326.11,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":8326.11,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":7425.93,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11312.16,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":8326.11,"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":8242.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":8242.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":8242.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":8242.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":8242.85,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":12072.86,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":8492.63,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":11451.84,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9676.39,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12619.13,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":8068.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":8068.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12619.13,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":8825.68,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":8326.11,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":11573.29,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":11813.99,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":9123.28,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":8159.59,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":7602.45,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":8742.42,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":8492.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":8492.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":8492.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":8492.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":8492.63,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":8908.94,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":12905.47,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":12905.47,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":12905.47,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":8742.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":8742.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":8742.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":8742.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":8742.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":8742.42,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":8409.37,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":8326.11,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":8126.28,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":8409.37,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":9158.72,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":8409.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":8409.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":8409.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":8409.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":8409.37,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":8242.85,"methodology":"fee schedule"}]}]},{"description":"DISORDERS OF PERSONALITY AND IMPULSE CONTROL  IPF","code_information":[{"code":"883","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1257.92,"maximum":1346.86,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":1334.16,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1257.92,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":1257.92,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":1257.92,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":1257.92,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":1257.92,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":1270.63,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":1270.63,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":1346.86,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":1270.63,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":1296.04,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":1296.04,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":1296.04,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":1296.04,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":1296.04,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":1270.63,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":1270.63,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":1270.63,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":1270.63,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":1270.63,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":1270.63,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":1270.63,"methodology":"fee schedule","additional_payer_notes":"Days 4. "}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC ","code_information":[{"code":"446","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":12300.00,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":7761.43,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":8256.84,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":8038.61,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":7863.66,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":7863.66,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":7174.65,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10929.37,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":7863.66,"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":7785.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":7785.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":7785.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":7785.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":7785.02,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":11402.31,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":8020.93,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":10613.12,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":8967.70,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":11694.92,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":7619.89,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":7619.89,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":11694.92,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":8335.48,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":7863.66,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":10930.49,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":10948.74,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":8455.10,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":7706.39,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":7045.65,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":8256.84,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":8020.93,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":8020.93,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":8020.93,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":8020.93,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":8020.93,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":8414.12,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":12188.67,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":12188.67,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":12188.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":8256.84,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":8256.84,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":8256.84,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":8256.84,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":8256.84,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":8256.84,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":7942.30,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":7863.66,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":7674.93,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  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"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":7727.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":7727.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":7727.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":7727.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":7727.43,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":8106.23,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":11742.66,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":11742.66,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":11742.66,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":7954.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":7954.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":7954.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":7954.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":7954.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":7954.71,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":7651.67,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":7575.91,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":7394.09,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":7651.67,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":8333.50,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":7651.67,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":7651.67,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":7651.67,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":7651.67,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":7651.67,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":7500.15,"methodology":"fee schedule"}]}]},{"description":"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC ","code_information":[{"code":"391","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":18849.48,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":11294.85,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":12015.80,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":12297.12,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":11443.62,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":11443.62,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":10975.47,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16719.29,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":11443.62,"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":11329.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":11329.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":11329.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":11329.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":11329.18,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":16593.25,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":11672.49,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":17105.87,"methodology":"fee schedule"},{"payer_name":"Healthcare 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Healthcare","plan_name":"HIX","standard_charge_dollar":17646.82,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":13627.65,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":11214.75,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":11355.95,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":12015.80,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":11672.49,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":11672.49,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":11672.49,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":11672.49,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":11672.49,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":12244.67,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":17737.61,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":17737.61,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":17737.61,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":12015.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":12015.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":12015.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":12015.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":12015.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":12015.80,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":11558.06,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":11443.62,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11168.97,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":11558.06,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":12587.98,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":11558.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":11558.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":11558.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":11558.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":11558.06,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":11329.18,"methodology":"fee schedule"}]}]},{"description":"Etanercept injection ","code_information":[{"code":"1608","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":774.97,"maximum":1621.10,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":797.50,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":830.32,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":790.78,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":790.78,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":790.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":790.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":790.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":790.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":790.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":790.78,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":1146.63,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":790.78,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":790.78,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":790.78,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":814.50,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":1099.19,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":1621.10,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":774.97,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":830.32,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":838.23,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":838.23,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":838.23,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":838.23,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":838.23,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":830.32,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":1225.71,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":1225.71,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":1146.63,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":830.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":830.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":830.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":830.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":830.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":830.32,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":790.78,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":794.73,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":798.69,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":1028.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":814.50,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":814.50,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":814.50,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":814.50,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":814.50,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":794.73,"methodology":"fee schedule"}]}]},{"description":"Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes (List separately in addition to code for ","code_information":[{"code":"92608","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":47.79,"maximum":504.24,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":49.69,"methodology":"fee schedule"},{"payer_name":"American Health 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(USFHP)","plan_name":"TRICARE","standard_charge_dollar":49.27,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":49.27,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":49.27,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":49.27,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":49.27,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":49.27,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":71.44,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":49.27,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":504.24,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":49.27,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":49.27,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":504.24,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":47.79,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":50.75,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":68.49,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":101.00,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":48.28,"methodology":"fee schedule"},{"payer_name":"ProCare 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IPA","plan_name":"MCR","standard_charge_dollar":53.45,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":68.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":54.51,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":54.51,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":54.51,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":54.51,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":54.51,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":53.18,"methodology":"fee schedule"}]}]},{"description":"EXTRAOCULAR PROCEDURES EXCEPT ORBIT ","code_information":[{"code":"115","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":22458.30,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":13077.15,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":13911.86,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":12171.35,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13099.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12180.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":13249.39,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":13249.39,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":11170.67,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20418.62,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":13249.39,"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":13116.90,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13116.90,"methodology":"fee schedule"},{"payer_name":"Cigna 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"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":13514.38,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":13514.38,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":13514.38,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":13514.38,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":13514.38,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":14176.85,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":20536.55,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":20536.55,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":20536.55,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":13911.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":13911.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":13911.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":13911.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":13911.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":13911.86,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":13381.88,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13249.39,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12931.40,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":13381.88,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":14574.33,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":13381.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":13381.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":13381.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":13381.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":13381.88,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13116.90,"methodology":"fee 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schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":2740.56,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":2740.56,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":2740.56,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":3470.16,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":3470.16,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":3470.16,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":544.32,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":630.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":1224.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":1950.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2184.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":600.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":600.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":1026.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1716.00,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":600.00,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":2810.79,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":3050.25,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3626.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":600.00,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":600.00,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":600.00,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":600.00,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":600.00,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":870.00,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":504.00,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":504.00,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":504.00,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":504.00,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":600.00,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":1350.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":630.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":600.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":600.00,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":618.00,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":834.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":554.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":1230.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":554.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":554.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":554.40,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":1650.00,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":588.00,"methodology":"fee 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Health","plan_name":"MGMCR","standard_charge_dollar":630.00,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":930.00,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":930.00,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":870.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":630.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":630.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":630.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":630.00,"methodology":"fee schedule"},{"payer_name":"Superior Health 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schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":618.00,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":618.00,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":618.00,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":618.00,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":618.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":603.00,"methodology":"fee schedule"}]}]},{"description":"Factor ix fc fusion recom ","code_information":[{"code":"1486","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":3.52,"maximum":7.36,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":3.62,"methodology":"fee schedule"},{"payer_name":"American Health 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Healthcare","plan_name":"CHIP","standard_charge_dollar":26.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":60.54,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":26.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":26.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":26.40,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":81.21,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":28.94,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":81.21,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":31.01,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":31.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":31.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":31.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":31.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":31.30,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":31.01,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":45.77,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":45.77,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":42.82,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":31.01,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":31.01,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":31.01,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":31.01,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":31.01,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":31.01,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":24.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":24.00,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":29.53,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":29.68,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":29.83,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":38.39,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":30.42,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":30.42,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":30.42,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":30.42,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":30.42,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":29.68,"methodology":"fee schedule"}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITH MCC ","code_information":[{"code":"974","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":43804.62,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":23619.45,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":25127.08,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":26485.28,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":23930.55,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":23930.55,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":23638.73,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":36009.65,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":23930.55,"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":23691.24,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":23691.24,"methodology":"fee schedule"},{"payer_name":"Cigna 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Healthcare","plan_name":"HIX","standard_charge_dollar":41009.72,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":31669.52,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":23451.94,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":26390.27,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":25127.08,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":24409.16,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":24409.16,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":24409.16,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":24409.16,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":24409.16,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":25605.69,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":37092.35,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":37092.35,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":37092.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":25127.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":25127.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":25127.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":25127.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":25127.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":25127.08,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":24169.86,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":23930.55,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":23356.22,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":24169.86,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":26323.60,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":24169.86,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":24169.86,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":24169.86,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":24169.86,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":24169.86,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":23691.24,"methodology":"fee 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schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":171.34,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":776.01,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":776.01,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":776.01,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":982.60,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":982.60,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":982.60,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":154.14,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":178.40,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":346.60,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":552.18,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":618.44,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":169.90,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":169.90,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":290.53,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":485.91,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":169.90,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":183.88,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":795.16,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":862.90,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1025.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":169.90,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":169.90,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":169.90,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":169.90,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":169.90,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":246.35,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":142.72,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":142.72,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":142.72,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":142.72,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":169.90,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":382.28,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":177.50,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":169.90,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":169.90,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":178.36,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":175.00,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":236.16,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":156.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":348.29,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":156.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":156.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":156.20,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":467.23,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":166.50,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":467.23,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":178.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":180.09,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":180.09,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":180.09,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":180.09,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":180.09,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":178.40,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":263.35,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":263.35,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":246.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":178.40,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":178.40,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":178.40,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":178.40,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":178.40,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":178.40,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":142.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":142.00,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":169.90,"methodology":"fee 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"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":28409.64,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":28409.64,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":28409.64,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":28409.64,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":28409.64,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":29802.27,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":43171.51,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":43171.51,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":43171.51,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":29245.22,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":29245.22,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":29245.22,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":29245.22,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":29245.22,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":29245.22,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":28131.12,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":27852.59,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":20199.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":27184.13,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":14992.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":19119.00,"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":13807.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":28131.12,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":30637.85,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":28131.12,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":28131.12,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":28131.12,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":28131.12,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":28131.12,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":27574.06,"methodology":"fee schedule"}]}]},{"description":"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC ","code_information":[{"code":"492","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":52093.17,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":22551.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":22551.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":26578.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":17742.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":17742.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":20909.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":27712.93,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":16460.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":28995.32,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13099.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12180.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, 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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"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":27404.07,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":13432.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":13770.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"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":13038.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. 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"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13099.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12180.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":18155.78,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":18155.78,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":18155.78,"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":17974.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":17974.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":17974.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":17974.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":17974.22,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":26325.88,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":18518.90,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":29279.28,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":24739.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":32263.73,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":17592.95,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":17592.95,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":32263.73,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":19245.13,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":18155.78,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":25236.53,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":30205.19,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":23325.78,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":17792.66,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":19437.41,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":19063.57,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":18518.90,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":18518.90,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":18518.90,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":18518.90,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":18518.90,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":19426.68,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":28141.46,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":28141.46,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":28141.46,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":19063.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":19063.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":19063.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":19063.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":19063.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":19063.57,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":18337.34,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":18155.78,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":17720.04,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":18337.34,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":19971.36,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":18337.34,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":18337.34,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":18337.34,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":18337.34,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":18337.34,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":17974.22,"methodology":"fee schedule"}]}]},{"description":"MAJ MULT TRAUMA NO BRAIN OR SPINAL CORD INJURY; M ","code_information":[{"code":"A1702","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":20689.84,"maximum":22632.85,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":22077.70,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":22419.33,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":21351.74,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":21138.23,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":21138.23,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":21138.23,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":21138.23,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":21138.23,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":20689.84,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":20689.84,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":22632.85,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":20924.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":21351.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":21351.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":21351.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":21351.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":21351.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":21351.74,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":21351.74,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":21351.74,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":20839.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":21351.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":21351.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":21351.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":21351.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":21351.74,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":21138.23,"methodology":"fee schedule"}]}]},{"description":"MAJ MULT TRAUMA W BRAIN OR SPINAL CORD INJURY; M > ","code_information":[{"code":"A1802","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":19048.00,"maximum":20836.82,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":20325.73,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":20640.25,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":19657.38,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":19460.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":19460.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":19460.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":19460.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":19460.81,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":19048.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":19048.00,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":20836.82,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":19264.23,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":19657.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":19657.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":19657.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":19657.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":19657.38,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":19657.38,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":19657.38,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":19657.38,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":19185.60,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":19657.38,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":19657.38,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":19657.38,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":19657.38,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":19657.38,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":19460.81,"methodology":"fee schedule"}]}]},{"description":"MAJOR CHEST PROCEDURES WITH MCC ","code_information":[{"code":"163","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":70185.32,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":35377.50,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":37635.63,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":41836.82,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13099.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12180.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":35843.46,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":35843.46,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":38397.15,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":70185.32,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":35843.46,"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":35485.03,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":35485.03,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":35485.03,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":35485.03,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":35485.03,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":51973.02,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":36560.33,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":61358.29,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":51845.52,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":67612.56,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":34732.31,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":34732.31,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":67612.56,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":37994.07,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":35843.46,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":49822.41,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":63298.63,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":48881.99,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":35126.59,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":40733.46,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":37635.63,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":36560.33,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":36560.33,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":36560.33,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":36560.33,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":36560.33,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":38352.50,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":55557.36,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":55557.36,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":55557.36,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":37635.63,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":37635.63,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":37635.63,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":37635.63,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":37635.63,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":37635.63,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":36201.89,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":35843.46,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":34983.22,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":36201.89,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":39427.81,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":36201.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":36201.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":36201.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":36201.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":36201.89,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":35485.03,"methodology":"fee schedule"}]}]},{"description":"MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC ","code_information":[{"code":"372","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":15099.83,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":9443.01,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":10045.76,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":10132.43,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":9567.39,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":9567.39,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":9043.43,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13776.15,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":9567.39,"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":9471.72,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":9471.72,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":9471.72,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":9471.72,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":9471.72,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":13872.72,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":9758.74,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":13703.07,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":11578.60,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":15099.83,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":9270.80,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":9270.80,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":15099.83,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":10141.43,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":9567.39,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":13298.67,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":14136.41,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":10916.76,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":9376.04,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":9096.95,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":10045.76,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":9758.74,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":9758.74,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":9758.74,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":9758.74,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":9758.74,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":10237.11,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":14829.46,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":14829.46,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":14829.46,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":10045.76,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":10045.76,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":10045.76,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":10045.76,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":10045.76,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":10045.76,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":9663.06,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":9567.39,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":9337.77,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":9663.06,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":10524.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":9663.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":9663.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":9663.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":9663.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":9663.06,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":9471.72,"methodology":"fee schedule"}]}]},{"description":"MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND CO ","code_information":[{"code":"810","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":13961.44,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":8880.80,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":9447.66,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":9466.97,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":8997.77,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":8997.77,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":8449.50,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12871.39,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":8997.77,"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":8907.79,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":8907.79,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":8907.79,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":8907.79,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":8907.79,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":13046.76,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":9177.72,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":12669.98,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":10705.67,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":13961.44,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":8718.84,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":8718.84,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":13961.44,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":9537.63,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":8997.77,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":12506.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":13070.65,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":10093.73,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":8817.81,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":8411.12,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":9447.66,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":9177.72,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":9177.72,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":9177.72,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":9177.72,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":9177.72,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":9627.61,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":13946.54,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":13946.54,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":13946.54,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":9447.66,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":9447.66,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":9447.66,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":9447.66,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":9447.66,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":9447.66,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":9087.75,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":8997.77,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":8781.82,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":9087.75,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":9897.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":9087.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":9087.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":9087.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":9087.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":9087.75,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":8907.79,"methodology":"fee schedule"}]}]},{"description":"MAJOR MULTIPLE TRAUMA NO BRAIN OR SPINAL CORD INJU ","code_information":[{"code":"C1701","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":19818.39,"maximum":21679.56,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":21147.79,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":21475.03,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":20452.41,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":20247.89,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":20247.89,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":20247.89,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":20247.89,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":20247.89,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":19818.39,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":19818.39,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":21679.56,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":20043.36,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":20452.41,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":20452.41,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":20452.41,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":20452.41,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":20452.41,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":20452.41,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":20452.41,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":20452.41,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":19961.55,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":20452.41,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":20452.41,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":20452.41,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":20452.41,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":20452.41,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":20247.89,"methodology":"fee schedule"}]}]},{"description":"MAJOR MULTIPLE TRAUMA WITH BRAIN OR SPINAL CORD IN ","code_information":[{"code":"B1801","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":20218.84,"maximum":22117.61,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":21575.10,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":21908.96,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":20865.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":20657.01,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":20657.01,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":20657.01,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":20657.01,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":20657.01,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":20218.84,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":20218.84,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":22117.61,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":20448.36,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":20865.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":20865.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":20865.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":20865.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":20865.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":20865.67,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":20865.67,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":20865.67,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":20364.90,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":20865.67,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":20865.67,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":20865.67,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":20865.67,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":20865.67,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":20657.01,"methodology":"fee schedule"}]}]},{"description":"MAJOR MULTIPLE TRAUMA,NO BRAIN OR SPINAL CORD INJU ","code_information":[{"code":"C1704","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":33117.09,"maximum":36227.16,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":35338.57,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":35885.39,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":34176.56,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":33834.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":33834.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":33834.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":33834.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":33834.80,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":33117.09,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":33117.09,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":36227.16,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":33493.03,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":34176.56,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":34176.56,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":34176.56,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":34176.56,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":34176.56,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":34176.56,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":34176.56,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":34176.56,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":33356.33,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":34176.56,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":34176.56,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":34176.56,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":34176.56,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":34176.56,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":33834.80,"methodology":"fee schedule"}]}]},{"description":"MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"331","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":24220.17,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":13947.28,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":14837.53,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":14292.94,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13099.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12180.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":14130.98,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":14130.98,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":13117.82,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":23977.79,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":14130.98,"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":13989.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13989.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":13989.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":13989.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":13989.67,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":20489.92,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":14413.60,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":21979.76,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":18572.10,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":24220.17,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":13692.92,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":13692.92,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":24220.17,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":14978.84,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":14130.98,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":19642.06,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":22674.83,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":17510.51,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":13848.36,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":14591.54,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":14837.53,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":14413.60,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":14413.60,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":14413.60,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":14413.60,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":14413.60,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":15120.15,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":21903.02,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":21903.02,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":21903.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":14837.53,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":14837.53,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":14837.53,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":14837.53,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":14837.53,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":14837.53,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":14272.29,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":14130.98,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13791.84,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":14272.29,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15544.08,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":14272.29,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":14272.29,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":14272.29,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":14272.29,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":14272.29,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13989.67,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC ","code_information":[{"code":"437","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":12300.00,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":7673.77,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":8163.58,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":7774.84,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":7774.84,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":7774.84,"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":7697.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":7697.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":7697.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":7697.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":7697.09,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":11273.52,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":7930.34,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":10452.04,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":8831.59,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":11517.42,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":7533.82,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":7533.82,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":11517.42,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":8241.33,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":7774.84,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":10807.03,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":10782.56,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":8326.77,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":7619.34,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":6938.71,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":8163.58,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":7930.34,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":7930.34,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":7930.34,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":7930.34,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":7930.34,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":8319.08,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":12051.00,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":12051.00,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":12051.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":8163.58,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":8163.58,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":8163.58,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":8163.58,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":8163.58,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":8163.58,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":7852.59,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":7774.84,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":7588.24,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":7852.59,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":8552.32,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":7852.59,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":7852.59,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":7852.59,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":7852.59,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":7852.59,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":7697.09,"methodology":"fee schedule"}]}]},{"description":"MALIGNANT BREAST DISORDERS WITH MCC ","code_information":[{"code":"597","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":25767.85,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":14711.63,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":15650.67,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":14905.40,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":14905.40,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":14905.40,"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":14756.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":14756.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":14756.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":14756.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":14756.35,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":21612.83,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":15203.51,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":23384.28,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":19758.87,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":25767.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":14443.33,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":14443.33,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":25767.85,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":15799.72,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":14905.40,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":20718.51,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":24123.77,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":18629.44,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":14607.29,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":15523.95,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":15650.67,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":15203.51,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":15203.51,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":15203.51,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":15203.51,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":15203.51,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":15948.78,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":23103.37,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":23103.37,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":23103.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":15650.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":15650.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":15650.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":15650.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":15650.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":15650.67,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":15054.45,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":14905.40,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":14547.67,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":15054.45,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":16395.94,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":15054.45,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":15054.45,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":15054.45,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":15054.45,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":15054.45,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":14756.35,"methodology":"fee 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schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":51.25,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":49.71,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":52.79,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":71.24,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":105.06,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":50.23,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":53.81,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":54.33,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":54.33,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":54.33,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":54.33,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":54.33,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":53.81,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":79.44,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":79.44,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":74.31,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":53.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":53.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":53.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":53.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":53.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":53.81,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":51.25,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":51.51,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":51.76,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":66.63,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":52.79,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":52.79,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":52.79,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":52.79,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":52.79,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":51.51,"methodology":"fee schedule"}]}]},{"description":"Manual wheelchair accessory, foam propulsion tire, any size, each ","code_information":[{"code":"E2218","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":48.15,"maximum":101.76,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":50.06,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":52.12,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":49.64,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":49.64,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":49.64,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":49.64,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":49.64,"methodology":"fee 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Plan","plan_name":"MCR","standard_charge_dollar":64.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":51.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":51.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":51.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":51.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":51.13,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":49.89,"methodology":"fee schedule"}]}]},{"description":"Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 inches ","code_information":[{"code":"E2204","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New 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","code_information":[{"code":"760","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":14457.28,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":9125.68,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":9708.17,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":9057.46,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":9245.88,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":9245.88,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":8084.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12314.62,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":9245.88,"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":9153.42,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":9153.42,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":9153.42,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":9153.42,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":9153.42,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":13406.52,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":9430.79,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":13119.96,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":11085.89,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":14457.28,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":8959.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":8959.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":14457.28,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":9800.63,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":9245.88,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":12851.77,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":13534.86,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":10452.21,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":9060.96,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":8709.85,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":9708.17,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":9430.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":9430.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":9430.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":9430.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":9430.79,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":9893.09,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":14331.11,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":14331.11,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":14331.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":9708.17,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":9708.17,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":9708.17,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":9708.17,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":9708.17,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":9708.17,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":9338.33,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":9245.88,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":9023.97,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":9338.33,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":10170.46,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":9338.33,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":9338.33,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":9338.33,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":9338.33,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":9338.33,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":9153.42,"methodology":"fee schedule"}]}]},{"description":"Metatarsal bar wedge, rocker ","code_information":[{"code":"L3400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":46.72,"maximum":386.87,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":48.57,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":50.57,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":48.16,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":48.16,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":48.16,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":48.16,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":48.16,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":48.16,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":48.16,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":48.16,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":48.16,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":69.83,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":48.16,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":386.87,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":48.16,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":48.16,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":386.87,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":46.72,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":49.60,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":66.94,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":98.73,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":47.20,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":50.57,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":51.05,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":51.05,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":51.05,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":51.05,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":51.05,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":50.57,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":74.65,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":74.65,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":69.83,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":50.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":50.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":50.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":50.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":50.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":50.57,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":48.16,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":48.40,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":48.64,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":62.61,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":49.60,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":49.60,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":49.60,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":49.60,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":49.60,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":48.40,"methodology":"fee schedule"}]}]},{"description":"Microphone for use with cochlear implant device, replacement ","code_information":[{"code":"L8616","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":120.77,"maximum":1000.30,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":125.57,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":130.74,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":124.51,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":124.51,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":124.51,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":124.51,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":124.51,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":124.51,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":124.51,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":124.51,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":124.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":180.54,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":124.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1000.30,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":124.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":124.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1000.30,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":120.77,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":128.25,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":173.07,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":255.25,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":122.02,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":130.74,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":131.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":131.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":131.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":131.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":131.98,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":130.74,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":192.99,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":192.99,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":180.54,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":130.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":130.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":130.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":130.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":130.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":130.74,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":124.51,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":125.13,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":125.76,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":161.86,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":128.25,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":128.25,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":128.25,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":128.25,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":128.25,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":125.13,"methodology":"fee schedule"}]}]},{"description":"MINOR BLADDER PROCEDURES WITH CC ","code_information":[{"code":"663","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":22421.79,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":13051.06,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":13884.11,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":13365.42,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13099.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12180.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":13222.96,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":13222.96,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":12266.57,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":22421.79,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":13222.96,"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":13090.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13090.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":13090.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":13090.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":13090.73,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":19173.29,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":13487.42,"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":"HMO","standard_charge_dollar":22405.49,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":12813.05,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":12813.05,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":22405.49,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":14016.34,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":13222.96,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":18379.91,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":20975.94,"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":12958.50,"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":13884.11,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":13487.42,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":13487.42,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":13487.42,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":13487.42,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":13487.42,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":14148.57,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":20495.59,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":20495.59,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":20495.59,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":13884.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":13884.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":13884.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":13884.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":13884.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":13884.11,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":13355.19,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13222.96,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12905.61,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":13355.19,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":14545.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":13355.19,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":13355.19,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":13355.19,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":13355.19,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":13355.19,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13090.73,"methodology":"fee schedule"}]}]},{"description":"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH M ","code_information":[{"code":"640","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":19483.23,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":11607.84,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":12348.77,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":12116.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":11760.73,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":11760.73,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":10813.81,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16473.03,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":11760.73,"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":11643.12,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":11643.12,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":11643.12,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":11643.12,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":11643.12,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":17053.06,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":11995.94,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":17681.00,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":14939.80,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":19483.23,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":11396.15,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":11396.15,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":19483.23,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":12466.37,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":11760.73,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":16347.41,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":18240.13,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":14085.83,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":11525.52,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":11737.75,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":12348.77,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":11995.94,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":11995.94,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":11995.94,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":11995.94,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":11995.94,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":12583.98,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":18229.13,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":18229.13,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":18229.13,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":12348.77,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":12348.77,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":12348.77,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":12348.77,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":12348.77,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":12348.77,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":11878.34,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":11760.73,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11478.47,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":11878.34,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":12936.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":11878.34,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":11878.34,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":11878.34,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":11878.34,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":11878.34,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":11643.12,"methodology":"fee schedule"}]}]},{"description":"MISCELLANEOUS; M > 27.85 & M < 38.75 ","code_information":[{"code":"C2003","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":26845.30,"maximum":29366.38,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":28646.07,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":29089.34,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":27704.13,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":27427.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":27427.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":27427.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":27427.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":27427.09,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":26845.30,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":26845.30,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":29366.38,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":27150.05,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":27704.13,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":27704.13,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":27704.13,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":27704.13,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":27704.13,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":27704.13,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":27704.13,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":27704.13,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":27039.23,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":27704.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":27704.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":27704.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":27704.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":27704.13,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":27427.09,"methodology":"fee schedule"}]}]},{"description":"MISCELLANEOUS; M > 49.15 ","code_information":[{"code":"C2001","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":17980.14,"maximum":19668.68,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":19186.24,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":19483.12,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":18555.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":18369.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":18369.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":18369.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":18369.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":18369.80,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":17980.14,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":17980.14,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":19668.68,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":18184.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":18555.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":18555.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":18555.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":18555.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":18555.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":18555.35,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health 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"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":29985.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":35275.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":38021.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":38021.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":44731.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":44543.89,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13099.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12180.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":42422.75,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":42422.75,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":42422.75,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":48248.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 11. 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"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":43271.21,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":43271.21,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":43271.21,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":43271.21,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":43271.21,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":45392.34,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":65755.26,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":65755.26,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":65755.26,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":44543.89,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":44543.89,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":44543.89,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":44543.89,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":44543.89,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":44543.89,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":42846.98,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":42422.75,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":61858.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":41404.60,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":46136.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":58548.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 6. 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","code_information":[{"code":"827","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":34616.80,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":19081.87,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":20299.86,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13099.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12180.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":19333.20,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":19333.20,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":19333.20,"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":19139.87,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":19139.87,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":19139.87,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":19139.87,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":19139.87,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":28033.14,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":19719.86,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":31414.69,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":26544.27,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":34616.80,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":18733.87,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":18733.87,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":34616.80,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":20493.19,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":19333.20,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":26873.15,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":32408.12,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":25026.98,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":18946.54,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":20855.03,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":20299.86,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":19719.86,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":19719.86,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":19719.86,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":19719.86,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":19719.86,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":20686.52,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":29966.46,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":29966.46,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":29966.46,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":20299.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":20299.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":20299.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":20299.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":20299.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":20299.86,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":19526.53,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":19333.20,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":18869.20,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":19526.53,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":21266.52,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":19526.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":19526.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":19526.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":19526.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":19526.53,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":19139.87,"methodology":"fee schedule"}]}]},{"description":"Nasal pillows for combination oral/nasal mask, replacement only, pair ","code_information":[{"code":"A7029","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":17.74,"maximum":37.49,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":18.45,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":19.20,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":18.29,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":18.29,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":18.29,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":18.29,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":18.29,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":18.29,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":18.29,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":18.29,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":18.29,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":26.52,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":18.29,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":18.29,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":18.29,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":17.74,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":18.84,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":25.42,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":37.49,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":17.92,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":19.20,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":19.39,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":19.39,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":19.39,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":19.39,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":19.39,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":19.20,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":28.35,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":28.35,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":26.52,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":19.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":19.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":19.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":19.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":19.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":19.20,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":18.29,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":18.38,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":18.47,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":23.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":18.84,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":18.84,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":18.84,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":18.84,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":18.84,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":18.38,"methodology":"fee schedule"}]}]},{"description":"Nebulizer, durable, glass or autoclavable plastic, bottle type, not used with oxygen ","code_information":[{"code":"A7017","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":119.96,"maximum":253.52,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":124.72,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":129.85,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":123.67,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":123.67,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":123.67,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":123.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":123.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":123.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":123.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":123.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":123.67,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":179.32,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":123.67,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":123.67,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":123.67,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":119.96,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":127.38,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":171.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":253.52,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":121.20,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":129.85,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":131.09,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":131.09,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":131.09,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":131.09,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":131.09,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":129.85,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":191.69,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":191.69,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":179.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":129.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":129.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":129.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":129.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":129.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":129.85,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":123.67,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":124.29,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":124.91,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":160.77,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":127.38,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":127.38,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":127.38,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":127.38,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":127.38,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":124.29,"methodology":"fee schedule"}]}]},{"description":"NEONATE WITH OTHER SIGNIFICANT PROBLEMS ","code_information":[{"code":"794","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1190.00,"maximum":17858.53,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":12680.84,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":13490.25,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":1406.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":2298.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2242.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":12847.86,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":12847.86,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":1190.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2354.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":3787.17,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":12847.86,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":12719.38,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":12719.38,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":12719.38,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":12719.38,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":12719.38,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":13104.82,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":5623.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":12449.58,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":12449.58,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":13618.73,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":12847.86,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":17858.53,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":12590.90,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":13490.25,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":13104.82,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":13104.82,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":13104.82,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":13104.82,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":13104.82,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13747.21,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":13490.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":13490.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":13490.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":13490.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":13490.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":13490.25,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":12976.34,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":12847.86,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3271.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12539.51,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":2827.00,"methodology":"per diem","additional_payer_notes":" 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":3097.00,"methodology":"per diem","additional_payer_notes":" 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":2236.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":12976.34,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":14132.65,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":12976.34,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":12976.34,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":12976.34,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":12976.34,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":12976.34,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":12719.38,"methodology":"fee schedule"}]}]},{"description":"Nephrology (renal transplant), RNA expression by select transcriptome sequencing, using posttransplant peripheral blood, algorithm reported as a risk score for acute cellular rejection ","code_information":[{"code":"0320U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2597.00,"maximum":11793.60,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":2672.53,"methodology":"fee schedule"},{"payer_name":"American Health 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Texas","plan_name":"PPO","standard_charge_dollar":21.95,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":21.95,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":21.74,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":32.10,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":32.10,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":30.03,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":21.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":21.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":21.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":21.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":21.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":21.74,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":20.71,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":20.81,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":20.92,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":26.92,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":21.33,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":21.33,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":21.33,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":21.33,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":21.33,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":20.81,"methodology":"fee schedule"}]}]},{"description":"ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY ","code_information":[{"code":"884","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1009.00,"maximum":24500.37,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":14085.66,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":1693.35,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":1193.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":1339.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1215.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":14271.19,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":14271.19,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":1009.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1463.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":14271.19,"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":14128.48,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":14128.48,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":14128.48,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":14128.48,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":14128.48,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":20693.23,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":14556.61,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":22234.04,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":18786.95,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":24500.37,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":13828.78,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":13828.78,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":24500.37,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":15127.46,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":14271.19,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":19836.95,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":17713.08,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":13985.77,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":14760.34,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":14984.75,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":14556.61,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":14556.61,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":14556.61,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":14556.61,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":14556.61,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":15270.17,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":14984.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":14984.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":14984.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":14984.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":14984.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":14984.75,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":14413.90,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":14271.19,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13928.68,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":14413.90,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15698.31,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":14413.90,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":14413.90,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":14413.90,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":14413.90,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":14413.90,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":14128.48,"methodology":"fee schedule"}]}]},{"description":"ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY  IPF","code_information":[{"code":"884","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1067.85,"maximum":1165.55,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":1165.55,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1067.85,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":1067.85,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":1067.85,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":1067.85,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":1067.85,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":1078.63,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":1078.63,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":1143.35,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":1078.63,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":1100.21,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":1100.21,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":1100.21,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":1100.21,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":1100.21,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":1078.63,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":1078.63,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":1078.63,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":1078.63,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":1078.63,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":1078.63,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":1078.63,"methodology":"fee schedule","additional_payer_notes":"Days 7. "}]}]},{"description":"Orthopedic shoe addition, insole, felt covered with leather ","code_information":[{"code":"L3520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":36.47,"maximum":302.13,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":37.92,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":39.48,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":37.60,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":37.60,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":37.60,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":37.60,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":37.60,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":37.60,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":37.60,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":37.60,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":37.60,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":54.52,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":37.60,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":302.13,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":37.60,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":37.60,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":302.13,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":36.47,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":38.73,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":52.26,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":77.08,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":36.85,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":39.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":39.86,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":39.86,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":39.86,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":39.86,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":39.86,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":39.48,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":58.28,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":58.28,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":54.52,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":39.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":39.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":39.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":39.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":39.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":39.48,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":37.60,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":37.79,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":37.98,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":48.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":38.73,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":38.73,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":38.73,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":38.73,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":38.73,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":37.79,"methodology":"fee schedule"}]}]},{"description":"Orthopedic shoe addition, toe tap, horseshoe ","code_information":[{"code":"L3560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":26.25,"maximum":217.30,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":27.29,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":28.41,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":27.06,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":27.06,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":27.06,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":27.06,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":27.06,"methodology":"fee schedule"},{"payer_name":"Cigna 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Healthcare","plan_name":"HIX","standard_charge_dollar":14.25,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":6.81,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":7.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":7.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":7.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":7.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":7.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":7.37,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":7.30,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":10.77,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":10.77,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":10.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":7.30,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":7.30,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":7.30,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":7.30,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":7.30,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":7.30,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":6.95,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":6.98,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":7.02,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":9.04,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":7.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":7.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":7.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":7.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":7.16,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6.98,"methodology":"fee schedule"}]}]},{"description":"Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4 x 4 inches or smaller, each ","code_information":[{"code":"A4407","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":11.59,"maximum":96.04,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":12.05,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":12.55,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":18.32,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":18.93,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":17.41,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":11.95,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":11.95,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":17.92,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20.46,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":11.95,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":11.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":11.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":11.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":11.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":11.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":11.95,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":17.33,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":11.95,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":96.04,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":11.95,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":11.95,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":96.04,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":11.59,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":12.31,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":16.61,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":24.50,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":11.71,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":12.55,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":12.67,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":12.67,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":12.67,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":12.67,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":12.67,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":12.55,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":18.52,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":18.52,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":17.33,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":12.55,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":12.55,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":12.55,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":12.55,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":12.55,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":12.55,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":11.95,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12.01,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":12.07,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":12.31,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":12.31,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":12.31,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":12.31,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":12.31,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":12.01,"methodology":"fee schedule"}]}]},{"description":"OTHER CARDIOTHORACIC PROCEDURES WITH MCC ","code_information":[{"code":"228","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":37392.55,"maximum":107336.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":86679.00,"methodology":"case rate","additional_payer_notes":"Days 0-15. "},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":86679.00,"methodology":"case rate","additional_payer_notes":"Days 0-15. "},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":86679.00,"methodology":"case rate","additional_payer_notes":"Days 0-15. "},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":68194.00,"methodology":"case rate","additional_payer_notes":"Days 0-15. "},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":68194.00,"methodology":"case rate","additional_payer_notes":"Days 0-15. "},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":68194.00,"methodology":"case rate","additional_payer_notes":"Days 0-15. "},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":38087.15,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":63271.00,"methodology":"case rate","additional_payer_notes":"Days 0-15. "},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":63271.00,"methodology":"case rate","additional_payer_notes":"Days 0-15. "},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":63271.00,"methodology":"case rate","additional_payer_notes":"Days 0-15. "},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":80231.00,"methodology":"case rate","additional_payer_notes":"Days 0-15. "},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":80231.00,"methodology":"case rate","additional_payer_notes":"Days 0-15. "},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":80231.00,"methodology":"case rate","additional_payer_notes":"Days 0-15. "},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":40518.24,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":73526.16,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $477476.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $9624 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":90540.48,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $682847.00, reimbursement will be the lesser of (a) 26% of billable gross charges, or (b) $11843 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":75018.64,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $682847.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $10638 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":38588.80,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":38588.80,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":57087.51,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $405854.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $8944 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":106062.31,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $682847.00, reimbursement will be the lesser of (a) 27.3% of billable gross charges, or (b) $13047 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":38588.80,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":83313.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 11. "},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":90245.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 11. "},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":107336.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 11. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":38202.91,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":38202.91,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":38202.91,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":38202.91,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":38202.91,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":55953.76,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":39360.58,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":66337.35,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":56052.64,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":73099.14,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":37392.55,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":37392.55,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":73099.14,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":40904.13,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":38588.80,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":53638.43,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":68435.15,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":52848.64,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":37817.02,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":44038.87,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":40518.24,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":39360.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":39360.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":39360.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":39360.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":39360.58,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":41290.02,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":59812.64,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":59812.64,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":59812.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":40518.24,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":40518.24,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":40518.24,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":40518.24,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":40518.24,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":40518.24,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":38974.69,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":38588.80,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":97900.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":37662.67,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":72658.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":92663.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 10. "},{"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":66921.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":38974.69,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":42447.68,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":38974.69,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":38974.69,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":38974.69,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":38974.69,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":38974.69,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":38202.91,"methodology":"fee schedule"}]}]},{"description":"OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"395","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":12300.00,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":6596.42,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":7017.47,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":6413.37,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":6683.31,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":6683.31,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":5724.08,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8719.68,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":6683.31,"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":6616.47,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":6616.47,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":6616.47,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":6616.47,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":6616.47,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":9690.80,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":6816.97,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":8472.39,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":7158.86,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":9335.99,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":6476.12,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":6476.12,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":9335.99,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7084.31,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":6683.31,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":9289.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":8740.32,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":6749.66,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":6549.64,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":5624.50,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":7017.47,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":6816.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":6816.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":6816.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":6816.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":6816.97,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":7151.14,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":10359.13,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":10359.13,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":10359.13,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":7017.47,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":7017.47,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":7017.47,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":7017.47,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":7017.47,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":7017.47,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":6750.14,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":6683.31,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":6522.91,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":6750.14,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":7351.64,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":6750.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":6750.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":6750.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":6750.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":6750.14,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6616.47,"methodology":"fee schedule"}]}]},{"description":"OTHER DISORDERS OF THE EYE WITHOUT MCC ","code_information":[{"code":"125","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":12512.94,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":7967.92,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":8476.51,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":8239.43,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":8072.86,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":8072.86,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":7353.88,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11202.41,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":8072.86,"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":7992.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":7992.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":7992.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":7992.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":7992.14,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":11705.65,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":8234.32,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":10992.54,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9288.30,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12113.02,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":7822.61,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":7822.61,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12113.02,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":8557.24,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":8072.86,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":11221.28,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":11340.16,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":8757.37,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":7911.41,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":7297.54,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":8476.51,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":8234.32,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":8234.32,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":8234.32,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":8234.32,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":8234.32,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":8637.96,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":12512.94,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":12512.94,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":12512.94,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":8476.51,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":8476.51,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":8476.51,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":8476.51,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":8476.51,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":8476.51,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":8153.59,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":8072.86,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":7879.12,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":8153.59,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":8880.15,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":8153.59,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":8153.59,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":8153.59,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":8153.59,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":8153.59,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":7992.14,"methodology":"fee schedule"}]}]},{"description":"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC ","code_information":[{"code":"628","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":57892.22,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":30576.90,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":32528.62,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 8. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":30745.07,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13099.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12180.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":30979.64,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":30979.64,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":28217.32,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":51577.83,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":30979.64,"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":30669.84,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":30669.84,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":30669.84,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":30669.84,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":30669.84,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":44920.48,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":31599.23,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":52537.09,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":44391.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":57892.22,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":30019.27,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":30019.27,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":57892.22,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":32838.42,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":30979.64,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":43061.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":54198.48,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":41854.46,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":30360.05,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":34877.40,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":32528.62,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 8. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":31599.23,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":31599.23,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":31599.23,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":31599.23,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":31599.23,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":33148.21,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":48018.44,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":48018.44,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":48018.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":32528.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":32528.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":32528.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":32528.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":32528.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":32528.62,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":31289.44,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":30979.64,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":30236.13,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":31289.44,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":34077.60,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":31289.44,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":31289.44,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":31289.44,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":31289.44,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":31289.44,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":30669.84,"methodology":"fee schedule"}]}]},{"description":"OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC ","code_information":[{"code":"424","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":33493.08,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":18526.89,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":19709.46,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":19085.94,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13099.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12180.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":18770.91,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":18770.91,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":17516.76,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":32018.51,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":18770.91,"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":18583.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":18583.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":18583.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":18583.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":18583.20,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":27217.82,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":19146.33,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":30394.91,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":25682.59,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":33493.08,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":18189.01,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":18189.01,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":33493.08,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":19897.16,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":18770.91,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":26091.56,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":31356.10,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":24214.56,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":18395.49,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":20178.04,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":19709.46,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":19146.33,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":19146.33,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":19146.33,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":19146.33,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":19146.33,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":20084.87,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":29094.91,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":29094.91,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":29094.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":19709.46,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":19709.46,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":19709.46,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":19709.46,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":19709.46,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":19709.46,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":18958.62,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":18770.91,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":18320.41,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":18958.62,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":20648.00,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":18958.62,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":18958.62,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":18958.62,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":18958.62,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":18958.62,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":18583.20,"methodology":"fee schedule"}]}]},{"description":"OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC ","code_information":[{"code":"699","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":14960.47,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":9374.19,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":9972.54,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":10109.79,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":9497.66,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":9497.66,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":9023.22,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13745.37,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":9497.66,"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":9402.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":9402.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":9402.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":9402.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":9402.68,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":13771.60,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":9687.61,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":13576.60,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":11471.73,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":14960.47,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":9203.23,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":9203.23,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":14960.47,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":10067.51,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":9497.66,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":13201.74,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":14005.93,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":10816.00,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":9307.70,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":9012.99,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":9972.54,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":9687.61,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":9687.61,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":9687.61,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":9687.61,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":9687.61,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":10162.49,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":14721.37,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":14721.37,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":14721.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":9972.54,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":9972.54,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":9972.54,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":9972.54,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":9972.54,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":9972.54,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":9592.63,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":9497.66,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":9269.71,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":9592.63,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":10447.42,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":9592.63,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":9592.63,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":9592.63,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":9592.63,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":9592.63,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":9402.68,"methodology":"fee schedule"}]}]},{"description":"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"272","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":60290.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":27384.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":27384.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":32216.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":21545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":21545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":25345.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":20112.84,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":19989.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":19989.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":23515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":25346.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":25346.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":29819.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":21396.64,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":37082.41,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $477476.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $9624 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":45663.46,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $682847.00, reimbursement will be the lesser of (a) 26% of billable gross charges, or (b) $11843 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":37835.13,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $682847.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $10638 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":20377.75,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":20377.75,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":28791.69,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $405854.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $8944 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":53491.79,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $682847.00, reimbursement will be the lesser of (a) 27.3% of billable gross charges, or (b) $13047 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":20377.75,"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":20173.97,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":20173.97,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":20173.97,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":20173.97,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":20173.97,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":29547.74,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":20785.31,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":33309.13,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":28145.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":36704.34,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":19746.04,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":19746.04,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":36704.34,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":21600.42,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":20377.75,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":28325.07,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":34362.47,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":26536.21,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":19970.19,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":22112.68,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":21396.64,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":20785.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":20785.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":20785.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":20785.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":20785.31,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":21804.19,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":31585.51,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":31585.51,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":31585.51,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":21396.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":21396.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":21396.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":21396.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":21396.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":21396.64,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":20581.53,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":20377.75,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":60290.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":19888.68,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":44745.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":57065.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":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":41213.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":20581.53,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":22415.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":20581.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":20581.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":20581.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":20581.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":20581.53,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":20173.97,"methodology":"fee schedule"}]}]},{"description":"OTHER MENTAL DISORDER DIAGNOSES ","code_information":[{"code":"887","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1009.00,"maximum":17447.03,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":10602.23,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":1567.92,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":1193.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":1339.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1215.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":10741.87,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":10741.87,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":1009.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1463.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":10741.87,"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":10634.45,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":10634.45,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":10634.45,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":10634.45,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":10634.45,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":15575.71,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":10956.71,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":15833.15,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":13378.44,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":17447.03,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":10408.87,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":10408.87,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":17447.03,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":11386.38,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":10741.87,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":14931.20,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":12613.72,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":10527.03,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":10511.03,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":11278.96,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":10956.71,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":10956.71,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":10956.71,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":10956.71,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":10956.71,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":11493.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":11278.96,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":11278.96,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":11278.96,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":11278.96,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":11278.96,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":11278.96,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":10849.29,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":10741.87,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":10484.07,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":10849.29,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":11816.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":10849.29,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":10849.29,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":10849.29,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":10849.29,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":10849.29,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":10634.45,"methodology":"fee schedule"}]}]},{"description":"OTHER MENTAL DISORDER DIAGNOSES  IPF","code_information":[{"code":"887","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":988.75,"maximum":1079.22,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":1079.22,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":988.75,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":988.75,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":988.75,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":988.75,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":988.75,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":998.74,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":998.74,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":1058.66,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":998.74,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":1018.71,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":1018.71,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":1018.71,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":1018.71,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":1018.71,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":998.74,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":998.74,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":998.74,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":998.74,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":998.74,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":998.74,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":998.74,"methodology":"fee schedule","additional_payer_notes":"Days 7. "}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"566","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":12300.00,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":7404.97,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":7877.63,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":7401.70,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":7502.51,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":7502.51,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":6606.19,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10063.43,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":7502.51,"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":7427.48,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":7427.48,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":7427.48,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":7427.48,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":7427.48,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":10878.64,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":7652.56,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":9958.12,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":8414.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":10973.16,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":7269.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":7269.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":10973.16,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7952.66,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":7502.51,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":10428.48,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":10273.03,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":7933.29,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":7352.46,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":6610.82,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":7877.63,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":7652.56,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":7652.56,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":7652.56,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":7652.56,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":7652.56,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":8027.68,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":11628.89,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":11628.89,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":11628.89,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":7877.63,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":7877.63,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":7877.63,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":7877.63,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":7877.63,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":7877.63,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":7577.53,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":7502.51,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":7322.45,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":7577.53,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":8252.76,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":7577.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":7577.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":7577.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":7577.53,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":7577.53,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":7427.48,"methodology":"fee schedule"}]}]},{"description":"OTHER O.R. PROCEDURES FOR INJURIES WITH MCC ","code_information":[{"code":"907","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":58437.94,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":30846.42,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":32815.35,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":32991.16,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13099.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12180.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":31252.71,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":31252.71,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":30278.75,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":55345.87,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":31252.71,"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":30940.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":30940.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":30940.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":30940.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":30940.18,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":45316.43,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":31877.76,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":53032.34,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":44810.39,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":58437.94,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":30283.88,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":30283.88,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":58437.94,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":33127.87,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":31252.71,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":43441.27,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":54709.39,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":42249.00,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":30627.66,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":35206.17,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":32815.35,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 6. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":31877.76,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":31877.76,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":31877.76,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":31877.76,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":31877.76,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":33440.40,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":48441.70,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":48441.70,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":48441.70,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":32815.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":32815.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":32815.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":32815.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":32815.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":32815.35,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":31565.24,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":31252.71,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":30502.64,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":31565.24,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":34377.98,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":31565.24,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":31565.24,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":31565.24,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":31565.24,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":31565.24,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":30940.18,"methodology":"fee schedule"}]}]},{"description":"OTHER ORTHOPEDIC; M < 24.15 ","code_information":[{"code":"A0904","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":27894.10,"maximum":30513.67,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":29765.22,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":30225.80,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":28786.48,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":28498.61,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":28498.61,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":28498.61,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":28498.61,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":28498.61,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":27894.10,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":27894.10,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":30513.67,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":28210.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":28786.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":28786.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":28786.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":28786.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":28786.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":28786.48,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":28786.48,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":28786.48,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":28095.60,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":28786.48,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":28786.48,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":28786.48,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":28786.48,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":28786.48,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":28498.61,"methodology":"fee schedule"}]}]},{"description":"OTHER ORTHOPEDIC; M > 34.35 & M < 44.75 ","code_information":[{"code":"A0902","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":19494.21,"maximum":21324.94,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":20801.88,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":21123.76,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":20117.87,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":19916.69,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":19916.69,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":19916.69,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":19916.69,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":19916.69,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":19494.21,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":19494.21,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":21324.94,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":19715.51,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":20117.87,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":20117.87,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":20117.87,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":20117.87,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":20117.87,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":20117.87,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":20117.87,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":20117.87,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":19635.04,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":20117.87,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":20117.87,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":20117.87,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":20117.87,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":20117.87,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":19916.69,"methodology":"fee schedule"}]}]},{"description":"OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC ","code_information":[{"code":"205","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":27692.56,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":15662.19,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":16661.90,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":16585.17,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":15868.48,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":15868.48,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":14802.65,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":22549.36,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":15868.48,"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":15709.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":15709.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":15709.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":15709.80,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":15709.80,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":23009.30,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":16185.85,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":25130.95,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":21234.74,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":27692.56,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":15376.56,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":15376.56,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":27692.56,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":16820.59,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":15868.48,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":22057.19,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":25925.67,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":20020.95,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":15551.11,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":16683.49,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":16661.90,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":16185.85,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":16185.85,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":16185.85,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":16185.85,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":16185.85,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":16979.27,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":24596.14,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":24596.14,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":24596.14,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":16661.90,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":16661.90,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":16661.90,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":16661.90,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":16661.90,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":16661.90,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":16027.16,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":15868.48,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":15487.64,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":16027.16,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":17455.33,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":16027.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":16027.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":16027.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":16027.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":16027.16,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":15709.80,"methodology":"fee schedule"}]}]},{"description":"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC ","code_information":[{"code":"579","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":47811.00,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":25598.09,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":27232.01,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":26278.78,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13099.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12180.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":25935.25,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":25935.25,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":24118.24,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":44085.21,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":25935.25,"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":25675.90,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":25675.90,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":25675.90,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":25675.90,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":25675.90,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":37606.11,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":26453.96,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":43388.40,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":36661.62,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":47811.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":25131.26,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":25131.26,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":47811.00,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":27491.37,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":25935.25,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":36050.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":44760.48,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":34566.01,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":25416.54,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":28803.93,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":27232.01,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":26453.96,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":26453.96,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":26453.96,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":26453.96,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":26453.96,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":27750.72,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":40199.64,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":40199.64,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":40199.64,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":27232.01,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":27232.01,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":27232.01,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":27232.01,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":27232.01,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":27232.01,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":26194.60,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":25935.25,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":25312.80,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  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Co","plan_name":"MCR","standard_charge_dollar":18335.74,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":16951.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":17297.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":17297.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":17297.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":17297.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":17297.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":17297.86,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health 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days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":17688.19,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":17688.19,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":16242.94,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":29690.12,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 multiplied by the number of medically necessary 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"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":18041.95,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":18041.95,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":18041.95,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":18041.95,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":18041.95,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":18926.36,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":27416.69,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":27416.69,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":27416.69,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":18572.60,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":18572.60,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":18572.60,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":18572.60,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":18572.60,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":18572.60,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":17865.07,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":17688.19,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":17263.67,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":17865.07,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":19457.01,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":17865.07,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":17865.07,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":17865.07,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":17865.07,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":17865.07,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":17511.31,"methodology":"fee 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schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":2693.47,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":2693.47,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":21639.94,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":2612.67,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":2774.27,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":3743.92,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":5521.61,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":2639.60,"methodology":"fee schedule"},{"payer_name":"ProCare 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schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":4174.88,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":3905.53,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":2828.14,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":2828.14,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":2828.14,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":2828.14,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":2828.14,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":2828.14,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":2693.47,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":2706.94,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":2720.40,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":3501.51,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":2774.27,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":2774.27,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":2774.27,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":2774.27,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":2774.27,"methodology":"fee 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schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":364.52,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":364.52,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":364.52,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":364.52,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":355.67,"methodology":"fee schedule"}]}]},{"description":"Patient lift, electric with seat or sling ","code_information":[{"code":"E0635","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":144.20,"maximum":304.75,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":149.92,"methodology":"fee schedule"},{"payer_name":"American Health 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schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":156.09,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":230.42,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":230.42,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":215.56,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":156.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":156.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":156.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":156.09,"methodology":"fee schedule"},{"payer_name":"Superior Health 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":18586.25,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13099.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12180.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":17446.69,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":17446.69,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":17058.16,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":31180.24,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":17446.69,"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":17272.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":17272.22,"methodology":"fee schedule"},{"payer_name":"Cigna 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"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":17795.62,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":17795.62,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":17795.62,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":17795.62,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":17795.62,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":18667.96,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":27042.37,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":27042.37,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":27042.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":18319.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":18319.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":18319.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":18319.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":18319.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":18319.02,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":17621.16,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":17446.69,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":17027.97,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":17621.16,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":19191.36,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":17621.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":17621.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":17621.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":17621.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":17621.16,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":17272.22,"methodology":"fee 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schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":59.97,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":59.97,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":59.97,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":59.97,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":59.97,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":86.96,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":59.97,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":59.97,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":59.97,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":58.17,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":61.77,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":83.36,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":122.94,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":58.77,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":62.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":63.57,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":63.57,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":63.57,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":63.57,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":63.57,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":62.97,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":92.95,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":92.95,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":86.96,"methodology":"fee schedule"},{"payer_name":"Superior Health 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IPA","plan_name":"MCR","standard_charge_dollar":60.57,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":77.96,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":61.77,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":61.77,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":61.77,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":61.77,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":61.77,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":60.27,"methodology":"fee schedule"}]}]},{"description":"Perfluroalkyl substances, 16 PFAS compounds by liquid chromatography with tandem mass spectrometry, plasma or serum, quantitative ","code_information":[{"code":"0394U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":41.19,"maximum":546.54,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":200.43,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":208.68,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":49.14,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":78.29,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":87.69,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":198.74,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":198.74,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":41.19,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":68.90,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":198.74,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":198.74,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":198.74,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":198.74,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":198.74,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":198.74,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":288.17,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":198.74,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":198.74,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":198.74,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":204.70,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":276.25,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":407.42,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":546.54,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":194.77,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":546.54,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":208.68,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":210.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":210.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":210.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":210.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":210.66,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":208.68,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":308.05,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":308.05,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":288.17,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":208.68,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":208.68,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":208.68,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":208.68,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":208.68,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":208.68,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":198.74,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":199.73,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":200.73,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":258.36,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":204.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":204.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":204.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":204.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":204.70,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":199.73,"methodology":"fee schedule"}]}]},{"description":"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"042","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":26651.02,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":14718.88,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":15658.39,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":15886.43,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13099.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12180.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":14912.75,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":14912.75,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":14580.30,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26651.02,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":14912.75,"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":14763.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":14763.62,"methodology":"fee schedule"},{"payer_name":"Cigna 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Healthcare","plan_name":"HIX","standard_charge_dollar":24137.51,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":18640.05,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":14614.49,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":15532.78,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":15658.39,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":15211.01,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":15211.01,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":15211.01,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":15211.01,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":15211.01,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":15956.64,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":23114.76,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":23114.76,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":23114.76,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":15658.39,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":15658.39,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":15658.39,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":15658.39,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":15658.39,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":15658.39,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":15061.88,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":14912.75,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":26183.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":14554.84,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":19432.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":24782.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":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":17897.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":15061.88,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":16404.03,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":15061.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":15061.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":15061.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":15061.88,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":15061.88,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":14763.62,"methodology":"fee schedule"}]}]},{"description":"Pertuzu, trastuzu, 10 mg ","code_information":[{"code":"9390","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":63.28,"maximum":132.38,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":65.12,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":67.80,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":64.58,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":64.58,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":64.58,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":64.58,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":64.58,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":64.58,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":64.58,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":64.58,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":93.64,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":64.58,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":64.58,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":64.58,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":66.51,"methodology":"fee 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days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":7400.47,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":7400.47,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":6409.39,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9763.63,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":7400.47,"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":7326.47,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":7326.47,"methodology":"fee schedule"},{"payer_name":"Cigna 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Healthcare","plan_name":"HIX","standard_charge_dollar":10082.13,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":7785.86,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":7252.46,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":6487.98,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":7770.50,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":7548.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":7548.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":7548.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":7548.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":7548.48,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":7918.51,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":11470.73,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":11470.73,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":11470.73,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":7770.50,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":7770.50,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":7770.50,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":7770.50,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":7770.50,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":7770.50,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":7474.48,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":7400.47,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":7222.86,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":7474.48,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":8140.52,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":7474.48,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":7474.48,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":7474.48,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":7474.48,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":7474.48,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":7326.47,"methodology":"fee schedule"}]}]},{"description":"PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant ","code_information":[{"code":"81326","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":39.00,"maximum":291.51,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":291.51,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":291.51,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":291.51,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":229.52,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":229.52,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":229.52,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":47.00,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":212.87,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":212.87,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":212.87,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":269.55,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":269.55,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":269.55,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":42.27,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":48.93,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":95.06,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":151.45,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":169.62,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":46.60,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":46.60,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":79.69,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":133.28,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":46.60,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":219.04,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":237.70,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":282.57,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":46.60,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":46.60,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":46.60,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":46.60,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":46.60,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":67.57,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":39.14,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":39.14,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":39.14,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":39.14,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":46.60,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":118.91,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":48.75,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":46.60,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":46.60,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":48.00,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":64.77,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":42.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":95.53,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":42.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":42.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":42.90,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":128.15,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":45.67,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":128.15,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":48.93,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":49.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":49.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":49.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":49.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":49.40,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":48.93,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":72.23,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":72.23,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":67.57,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":48.93,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":48.93,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":48.93,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":48.93,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":48.93,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":48.93,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":39.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":39.00,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":46.60,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":46.83,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":47.07,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":60.58,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":48.00,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":48.00,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":48.00,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":48.00,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":48.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":46.83,"methodology":"fee schedule"}]}]},{"description":"Pneumatic compressor, segmental home model without calibrated gradient pressure ","code_information":[{"code":"E0651","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New 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schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":1253.12,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":1253.12,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":1253.12,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":1817.02,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":1253.12,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":1253.12,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":1253.12,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":1215.53,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":1290.71,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":1741.84,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":2568.90,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":1228.06,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":1315.78,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":1328.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":1328.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":1328.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":1328.31,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":1328.31,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":1315.78,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":1942.34,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":1942.34,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":1817.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":1315.78,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":1315.78,"methodology":"fee schedule"},{"payer_name":"Superior Health 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schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":1290.71,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":1290.71,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":1290.71,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":1290.71,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":1290.71,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":1259.39,"methodology":"fee schedule"}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC  IPF","code_information":[{"code":"917","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1142.34,"maximum":1223.11,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":1211.57,"methodology":"fee 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","code_information":[{"code":"E2613","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":340.26,"maximum":719.10,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":353.76,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":368.32,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":350.78,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":350.78,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":350.78,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":350.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":350.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":350.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":350.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":350.78,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":350.78,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":508.63,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":350.78,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":350.78,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":350.78,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":340.26,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":361.30,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":487.58,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":719.10,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":343.76,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":368.32,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":371.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":371.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":371.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":371.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":371.83,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":368.32,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":543.71,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":543.71,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":508.63,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":368.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":368.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":368.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":368.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":368.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":368.32,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":350.78,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":352.53,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":354.29,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":456.01,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":361.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":361.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":361.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":361.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":361.30,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":352.53,"methodology":"fee schedule"}]}]},{"description":"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC ","code_information":[{"code":"863","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":14668.53,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":9230.01,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":9819.16,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":9956.22,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":9351.58,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":9351.58,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":8886.16,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13536.58,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":9351.58,"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":9258.06,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":9258.06,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":9258.06,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":9258.06,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":9258.06,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":13559.79,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":9538.61,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":13311.67,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":11247.88,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":14668.53,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":9061.68,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":9061.68,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":14668.53,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":9912.67,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":9351.58,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":12998.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":13732.63,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":10604.94,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":9164.55,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":8837.12,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":9819.16,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":9538.61,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":9538.61,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":9538.61,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":9538.61,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":9538.61,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":10006.19,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":14494.95,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":14494.95,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":14494.95,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":9819.16,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":9819.16,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":9819.16,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":9819.16,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":9819.16,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":9819.16,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":9445.10,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":9351.58,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":9127.14,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":9445.10,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":10286.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":9445.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":9445.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":9445.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":9445.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":9445.10,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":9258.06,"methodology":"fee schedule"}]}]},{"description":"Potassium; urine ","code_information":[{"code":"84133","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3.00,"maximum":29.55,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":29.55,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":29.55,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":29.55,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":23.26,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":23.26,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":23.26,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":4.77,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":21.58,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":21.58,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":21.58,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":27.32,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":27.32,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":27.32,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":4.29,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":4.97,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":9.65,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":15.37,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":17.22,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":4.73,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":4.73,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":8.09,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13.53,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":4.73,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":5.12,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":22.23,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":24.13,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":28.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":4.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":4.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":4.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":4.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":4.73,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":6.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":3.97,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":3.97,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":3.97,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":3.97,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":4.73,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":11.97,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":3.75,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":4.73,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":4.73,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":4.97,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":4.87,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":6.57,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":3.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":9.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":3.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":3.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":3.30,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":13.01,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":4.64,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":13.01,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":4.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":5.01,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":5.01,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":5.01,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of 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Healthcare","plan_name":"HIX","standard_charge_dollar":39374.00,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":30406.34,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":22595.17,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":25337.66,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":24209.12,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":23517.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":23517.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":23517.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":23517.43,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":23517.43,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":24670.24,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":35737.26,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":35737.26,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":35737.26,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":24209.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":24209.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":24209.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":24209.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":24209.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":24209.12,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":23286.86,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":23056.30,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":22502.95,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":23286.86,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":25361.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":23286.86,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":23286.86,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":23286.86,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":23286.86,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":23286.86,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":22825.74,"methodology":"fee 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schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":7.21,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":7.21,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":7.21,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":5.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":5.00,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":6.87,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":6.90,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":6.94,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":8.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":7.08,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":7.08,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":7.08,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":7.08,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":7.08,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6.90,"methodology":"fee schedule"}]}]},{"description":"Tissue culture for neoplastic disorders; solid tumor ","code_information":[{"code":"88239","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":123.00,"maximum":922.75,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":922.75,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":922.75,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":922.75,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":726.54,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":726.54,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":726.54,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":148.77,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":673.84,"methodology":"fee 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schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":536.97,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":147.52,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":147.52,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":252.26,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":421.91,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":147.52,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":159.66,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":690.40,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":749.21,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":890.65,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":147.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":147.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":147.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":147.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":147.52,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":213.90,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":123.92,"methodology":"fee schedule"},{"payer_name":"Community Health Choice 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Healthplans","plan_name":"MEDICAID","standard_charge_dollar":276.00,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":329.51,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":331.16,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":332.81,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":428.36,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":339.40,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":339.40,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":339.40,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":339.40,"methodology":"fee 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days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":21462.68,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":21462.68,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":20888.82,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":38182.23,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 multiplied by the number of medically necessary 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"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":21891.93,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":21891.93,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":21891.93,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":21891.93,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":21891.93,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":22965.07,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":33267.15,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":33267.15,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":33267.15,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":22535.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":22535.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":22535.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":22535.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":22535.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":22535.81,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":21677.31,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":21462.68,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":20947.58,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  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"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":26042.90,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":26042.90,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":26042.90,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":26042.90,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":26042.90,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":27319.51,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":39574.99,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":39574.99,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":39574.99,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":26808.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":26808.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":26808.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":26808.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":26808.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":26808.86,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":25787.57,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":25532.25,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":36804.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":24919.48,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":27315.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":34835.00,"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":25157.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":25787.57,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":28085.48,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":25787.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":25787.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":25787.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":25787.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":25787.57,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":25276.93,"methodology":"fee schedule"}]}]},{"description":"UNCOMPLICATED PEPTIC ULCER WITHOUT MCC ","code_information":[{"code":"384","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":13012.42,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":8285.98,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":8814.87,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":8788.72,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":8395.11,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":8395.11,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":7844.14,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11949.24,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":8395.11,"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":8311.16,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":8311.16,"methodology":"fee schedule"},{"payer_name":"Cigna 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Texas","plan_name":"SNP","standard_charge_dollar":4086.65,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":4048.10,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":5975.76,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":5975.76,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":5590.23,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":4048.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":4048.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":4048.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":4048.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":4048.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":4048.10,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":3855.33,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":3874.61,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":3893.88,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":5011.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":3970.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":3970.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":3970.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":3970.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":3970.99,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":3874.61,"methodology":"fee schedule"}]}]},{"description":"Upper extremity addition, test socket, elbow disarticulation or above elbow ","code_information":[{"code":"L6682","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":344.40,"maximum":2852.46,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":358.07,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":372.80,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":355.05,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":355.05,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":355.05,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":355.05,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":355.05,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":355.05,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":355.05,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":355.05,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":355.05,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":514.82,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":355.05,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":2852.46,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":355.05,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":355.05,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":2852.46,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":344.40,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":365.70,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":493.52,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":727.85,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":347.95,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":372.80,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":376.35,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":376.35,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":376.35,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":376.35,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":376.35,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":372.80,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":550.33,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":550.33,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":514.82,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":372.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":372.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":372.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":372.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":372.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":372.80,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":355.05,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":356.83,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":358.60,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":461.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":365.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":365.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":365.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":365.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":365.70,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":356.83,"methodology":"fee schedule"}]}]},{"description":"Upper extremity fracture orthosis, humeral, prefabricated, includes shoulder cap design, with or without joints, forearm section, may include soft interface, straps, includes fitting and adjustments ","code_information":[{"code":"L3981","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1051.11,"maximum":8706.00,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":1092.83,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":1137.80,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":1083.62,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":1083.62,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":1083.62,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":1083.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1083.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":1083.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":1083.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":1083.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":1083.62,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":1571.25,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":1083.62,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":8706.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":1083.62,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":1083.62,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":8706.00,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":1051.11,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":1116.13,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":1506.23,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":2221.42,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":1061.95,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":1137.80,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":1148.64,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":1148.64,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":1148.64,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":1148.64,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":1148.64,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":1137.80,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":1679.61,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":1679.61,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":1571.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":1137.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":1137.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":1137.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":1137.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":1137.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":1137.80,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":1083.62,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1089.04,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":1094.46,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":1408.71,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":1116.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":1116.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":1116.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":1116.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":1116.13,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":1089.04,"methodology":"fee schedule"}]}]},{"description":"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"257","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":16333.77,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":8447.54,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":8986.75,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":9736.41,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13099.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12180.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":8558.81,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":8558.81,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":8935.92,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16333.77,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":8558.81,"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":8473.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":8473.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":8473.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":8473.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":8473.22,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":12410.27,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":8729.98,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":11873.86,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":10032.98,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":13084.17,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":8293.48,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":8293.48,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":13084.17,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":9072.33,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":8558.81,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":11896.74,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":12249.35,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":9459.49,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":8387.63,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":7882.61,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":8986.75,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":8729.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":8729.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":8729.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":8729.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":8729.98,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":9157.92,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":13266.15,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":13266.15,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":13266.15,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":8986.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":8986.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":8986.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":8986.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":8986.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":8986.75,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":8644.39,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":8558.81,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":8353.39,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":8644.39,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":9414.69,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":8644.39,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":8644.39,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":8644.39,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":8644.39,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":8644.39,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":8473.22,"methodology":"fee schedule"}]}]},{"description":"URETHRAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"672","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":16126.31,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":9913.94,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":10546.75,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":9612.74,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13099.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12180.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":10044.52,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":10044.52,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":8822.42,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16126.31,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":10044.52,"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":9944.07,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":9944.07,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":9944.07,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":9944.07,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":9944.07,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":14564.55,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":10245.41,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":14568.42,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":12309.78,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":16053.38,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":9733.14,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":9733.14,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":16053.38,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":10647.19,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":10044.52,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":13961.88,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":15029.12,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":11606.15,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":9843.63,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":9671.42,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":10546.75,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":10245.41,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":10245.41,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":10245.41,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":10245.41,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":10245.41,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":10747.64,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":15569.01,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":15569.01,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":15569.01,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":10546.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":10546.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":10546.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":10546.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":10546.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":10546.75,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":10144.97,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":10044.52,"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":"MCR","standard_charge_dollar":9803.45,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":10144.97,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":11048.97,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":10144.97,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":10144.97,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":10144.97,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":10144.97,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":10144.97,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":9944.07,"methodology":"fee schedule"}]}]},{"description":"Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automate ","code_information":[{"code":"81000","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3.00,"maximum":25.18,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":25.18,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":25.18,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":25.18,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":19.83,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":19.83,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":19.83,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":4.05,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":18.39,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":18.39,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":18.39,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":23.29,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":23.29,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":23.29,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":3.65,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":4.22,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":8.20,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13.06,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.63,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":4.02,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":4.02,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":6.87,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11.50,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":4.02,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":4.35,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":19.03,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":20.65,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":24.55,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":4.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":4.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":4.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":4.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":4.02,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":5.83,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":3.38,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":3.38,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":3.38,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":3.38,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":4.02,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9.04,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":3.75,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":4.02,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":4.02,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":4.22,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":4.14,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":5.59,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":3.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":8.24,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":3.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":3.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":3.30,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":11.05,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":3.94,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":11.05,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":4.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":4.26,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":4.26,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":4.26,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":4.26,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":4.26,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":4.22,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":6.23,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":6.23,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":5.83,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":4.22,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":4.22,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":4.22,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":4.22,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":4.22,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":4.22,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":3.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":3.00,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":4.02,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":4.04,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":4.06,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":5.23,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":4.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":4.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":4.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":4.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":4.14,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":4.04,"methodology":"fee schedule"}]}]},{"description":"Urinary drainage bag, leg or abdomen, latex, with or without tube, with straps, each ","code_information":[{"code":"A5112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":38.96,"maximum":322.59,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":40.50,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":42.17,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":61.54,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":63.59,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":58.46,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":40.16,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":40.16,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":60.17,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":68.72,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":40.16,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":40.16,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":40.16,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":40.16,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":40.16,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":40.16,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":40.16,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":58.23,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":40.16,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":322.59,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":40.16,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":40.16,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":322.59,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":38.96,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":41.36,"methodology":"fee 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"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11803.73,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":10529.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":13430.00,"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":9699.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":12214.93,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":13303.39,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":12214.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":12214.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":12214.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":12214.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":12214.93,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":11973.05,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITH O.R. 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schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":590.52,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":590.52,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":590.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":590.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":590.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":590.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":590.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":590.52,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":856.26,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":590.52,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":590.52,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":590.52,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":608.24,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":820.83,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":1210.57,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":578.71,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":620.05,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":625.96,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":625.96,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":625.96,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":625.96,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":625.96,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":620.05,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":915.31,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":915.31,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":856.26,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":620.05,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":620.05,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":620.05,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":620.05,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":620.05,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":620.05,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":590.52,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":593.48,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":596.43,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":767.68,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":608.24,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":608.24,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":608.24,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":608.24,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":608.24,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":593.48,"methodology":"fee schedule"}]}]},{"description":"VIRAL ILLNESS WITHOUT MCC ","code_information":[{"code":"866","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":13184.23,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":8395.38,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":8931.25,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":8259.12,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":8505.95,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":8505.95,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":7371.45,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11229.18,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":8505.95,"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":8420.89,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":8420.89,"methodology":"fee schedule"},{"payer_name":"Cigna 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Healthcare","plan_name":"HIX","standard_charge_dollar":12150.47,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":9383.13,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":8335.83,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":7818.98,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":8931.25,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":8676.07,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":8676.07,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":8676.07,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":8676.07,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":8676.07,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":9101.37,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":13184.23,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":13184.23,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":13184.23,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":8931.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":8931.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":8931.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":8931.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":8931.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":8931.25,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":8591.01,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":8505.95,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":8301.81,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":8591.01,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":9356.55,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":8591.01,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":8591.01,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":8591.01,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":8591.01,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":8591.01,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":8420.89,"methodology":"fee 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schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":20.37,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":92.25,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":92.25,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":92.25,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":116.81,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":116.81,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":116.81,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":18.33,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":21.21,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":41.21,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":65.65,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":73.53,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":20.20,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":20.20,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":34.54,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":57.77,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":20.20,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":21.86,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":95.25,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":103.36,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":122.88,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":20.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":20.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":20.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":20.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":20.20,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":29.29,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":16.97,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":16.97,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":16.97,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":16.97,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":20.20,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":56.12,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":20.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":20.20,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":20.20,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":21.20,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":20.81,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":28.08,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":17.60,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":41.41,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":17.60,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":17.60,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":17.60,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":55.55,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":19.80,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":55.55,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":21.21,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":21.41,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":21.41,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":21.41,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":21.41,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":21.41,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":21.21,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":31.31,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":31.31,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":29.29,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":21.21,"methodology":"fee schedule"},{"payer_name":"Superior Health 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IPF","code_information":[{"code":"880","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1192.26,"maximum":1276.56,"payers_information":[{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":1264.52,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1192.26,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":1192.26,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":1192.26,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":1192.26,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":1192.26,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":1204.30,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":1204.30,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":1276.56,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":1204.30,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":1228.39,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":1228.39,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":1228.39,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":1228.39,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":1228.39,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":1204.30,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":1204.30,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":1204.30,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":1204.30,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":1204.30,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":1204.30,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":1204.30,"methodology":"fee schedule","additional_payer_notes":"Days 3. "}]}]},{"description":"ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC ","code_information":[{"code":"288","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4523.00,"maximum":40068.17,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":21774.14,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":23163.98,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":26435.08,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":22060.93,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":22060.93,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":23593.92,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":35941.39,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 multiplied by the number of medically necessary 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"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":22502.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":22502.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":22502.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":22502.15,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":22502.15,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":23605.20,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":34194.44,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":34194.44,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":34194.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":23163.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":23163.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":23163.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":23163.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":23163.98,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":23163.98,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":22281.54,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":22060.93,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19901.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 9. "},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":21531.47,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":14770.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 9. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":18836.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 9. "},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":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":13604.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 9. "},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":22281.54,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":24267.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":22281.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":22281.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":22281.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":22281.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":22281.54,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":21840.32,"methodology":"fee schedule"}]}]},{"description":"ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC ","code_information":[{"code":"122","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4411.00,"maximum":12300.00,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":6899.99,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":7340.42,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":6354.30,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":6990.87,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":6990.87,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":5671.36,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8639.37,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":6990.87,"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":6920.97,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":6920.97,"methodology":"fee schedule"},{"payer_name":"Cigna 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"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":7130.69,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":7130.69,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":7130.69,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":7130.69,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":7130.69,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":7480.24,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":10835.85,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":10835.85,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":10835.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":7340.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":7340.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":7340.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":7340.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":7340.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":7340.42,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":7060.78,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":6990.87,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":6823.09,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":7060.78,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":7689.96,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":7060.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":7060.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":7060.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":7060.78,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":7060.78,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6920.97,"methodology":"fee schedule"}]}]},{"description":"Acylcarnitines; quantitative, each specimen ","code_information":[{"code":"300478","type":"CDM"},{"code":"82017","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.00,"maximum":105.51,"gross_charge":891.08,"discounted_cash":891.08,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":105.51,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":105.51,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":105.51,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":83.07,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":83.07,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":83.07,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":17.01,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":77.05,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":77.05,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":77.05,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":97.56,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":97.56,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":97.56,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":15.30,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":17.71,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":34.41,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":54.83,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":61.41,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":16.87,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":16.87,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":28.85,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":48.25,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":16.87,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":18.26,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":79.37,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":86.14,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":102.40,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":16.87,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":16.87,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":16.87,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":16.87,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":16.87,"methodology":"fee schedule"},{"payer_name":"Community Health 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schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":16.87,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":16.87,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":17.71,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":17.38,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":23.45,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":15.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":34.58,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":15.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":15.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":15.40,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":46.39,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":16.53,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":46.39,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":17.71,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":17.88,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":17.88,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":17.88,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":17.88,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":17.88,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":17.71,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":26.15,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":26.15,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":24.46,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":17.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":17.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":17.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":17.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":17.71,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":17.71,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":14.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":14.00,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":16.87,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16.95,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":17.04,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":21.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":17.38,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":17.38,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":17.38,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":17.38,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":17.38,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":16.95,"methodology":"fee schedule"}]}]},{"description":"Addition to ctlso or scoliosis orthosis, lumbar bolster pad ","code_information":[{"code":"L1030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":90.51,"maximum":749.69,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":94.10,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":97.98,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":93.31,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":93.31,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":93.31,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":93.31,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":93.31,"methodology":"fee schedule"},{"payer_name":"Cigna 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schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":93.31,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":749.69,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":90.51,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":96.11,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":129.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":191.29,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":91.44,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":97.98,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":98.91,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":98.91,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":98.91,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":98.91,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":98.91,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":97.98,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":144.63,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":144.63,"methodology":"fee 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":14273.80,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12300.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11216.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":12797.95,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":12797.95,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":12739.70,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":19406.80,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":12797.95,"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":12669.97,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":12669.97,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":12669.97,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":12669.97,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":12669.97,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":18557.03,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":13053.91,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":19562.12,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":16529.28,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":21556.10,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":12401.21,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":12401.21,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":21556.10,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":13565.83,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":12797.95,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":17789.15,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":20180.74,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":15584.46,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":12541.99,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":12986.56,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":13437.85,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":13053.91,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":13053.91,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":13053.91,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":13053.91,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":13053.91,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13693.81,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":19836.82,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":19836.82,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":19836.82,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":13437.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":13437.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":13437.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":13437.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":13437.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":13437.85,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":12925.93,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":12797.95,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6866.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12490.80,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6499.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":4411.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":12925.93,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":14077.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":12925.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":12925.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":12925.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":12925.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":12925.93,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":12669.97,"methodology":"fee schedule"}]}]},{"description":"CERVICAL SPINAL FUSION WITH CC ","code_information":[{"code":"472","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8230.00,"maximum":42806.77,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":11274.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":11274.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":13290.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":8871.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":8871.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":10456.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":22974.65,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":8230.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":8230.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":9701.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":10436.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":10436.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":12300.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":24441.11,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":25516.72,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 17.2% of billable gross charges, or (b) $6554 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":13099.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $541162.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $10179 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12180.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 24.3% of billable gross charges, or (b) $9240 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":23277.25,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":23277.25,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":23418.83,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 14.5% of billable gross charges, or (b) $5883 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":42806.77,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $557056.00, reimbursement will be the lesser of (a) 24.2% of billable gross charges, or (b) $11118 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":23277.25,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":18825.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":20390.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":24252.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":23044.48,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":23044.48,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":23044.48,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":23044.48,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":23044.48,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":33752.01,"methodology":"fee schedule"},{"payer_name":"Coventry National First Health","plan_name":"COMM","standard_charge_percentage":36.10,"standard_charge_algorithm":"Reimbursement will be 36.1% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":23742.80,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":38567.76,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":32588.35,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":42498.99,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":22555.66,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":22555.66,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":42498.99,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":24673.89,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":23277.25,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":32355.38,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":39787.40,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":30725.58,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":22811.70,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":25603.69,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":24441.11,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":23742.80,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":23742.80,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":23742.80,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":23742.80,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":23742.80,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":24906.66,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":36079.74,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":36079.74,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":36079.74,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":24441.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":24441.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":24441.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":24441.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":24441.11,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":24441.11,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":23510.02,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":23277.25,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17599.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":22718.60,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":13009.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":16657.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"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":14815.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":23510.02,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":25604.98,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":23510.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":23510.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":23510.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":23510.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":23510.02,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":23044.48,"methodology":"fee schedule"}]}]},{"description":"Cervical, flexible, non-adjustable, prefabricated, off-the-shelf (foam collar) ","code_information":[{"code":"L0120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":28.32,"maximum":234.54,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":29.45,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":30.66,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":29.20,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":29.20,"methodology":"fee schedule"},{"payer_name":"CHC Harris Health","plan_name":"Indigent","standard_charge_dollar":29.20,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":29.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":29.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":29.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":29.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":29.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":29.20,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":42.34,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":29.20,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":234.54,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":29.20,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":29.20,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":234.54,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICARE","standard_charge_dollar":28.32,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":30.08,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":40.59,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":59.86,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":28.62,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":30.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of 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Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":1144.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":1144.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":3034.92,"methodology":"fee schedule"}]}]},{"description":"TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE ","code_information":[{"code":"0051","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":40535.00,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":37616.98,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":34049.40,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":34049.40,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":34049.40,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":34049.40,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":40535.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":34049.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":34049.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":34049.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":34049.40,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":32428.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":32428.00,"methodology":"fee 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Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":3874.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":3874.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":3951.48,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; ","code_information":[{"code":"58541","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1987.00,"maximum":17479.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":9237.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":10005.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":11899.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Community 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Healthcare","plan_name":"STARPLUS","standard_charge_dollar":2260.50,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":2055.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":2055.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":5490.85,"methodology":"fee schedule"}]}]},{"description":"Lymphangiography, extremity only, bilateral, radiological supervision and interpretation ","code_information":[{"code":"75803","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":299.00,"maximum":14125.90,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":14125.90,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":14125.90,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":14125.90,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":11113.93,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":11113.93,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":11113.93,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":10308.41,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":10308.41,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":10308.41,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":13075.22,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":13075.22,"methodology":"fee 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schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":715.29,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":299.60,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":299.60,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":299.60,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":299.60,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":373.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":328.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":328.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":328.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":328.90,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":299.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":299.00,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar ","code_information":[{"code":"72158","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":333.00,"maximum":2063.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":2063.00,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":2063.00,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":2063.00,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":1623.00,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":1623.00,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":1623.00,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":1506.00,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":1506.00,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":1506.00,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":1910.00,"methodology":"per diem"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":1910.00,"methodology":"per 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schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":333.80,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":333.80,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":416.25,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":366.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":366.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":366.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":366.30,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":333.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":333.00,"methodology":"fee schedule"}]}]},{"description":"MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY ","code_information":[{"code":"5011","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":2286.25,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":2121.77,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":1920.45,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":1920.45,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":1920.45,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":1920.45,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":2286.25,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1920.45,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1920.45,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1920.45,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1920.45,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":1829.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":1829.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":1865.58,"methodology":"fee schedule"}]}]},{"description":"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS ","code_information":[{"code":"5324","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":12860.00,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":11934.71,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":10802.40,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":10802.40,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":10802.40,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":10802.40,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":12860.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":10802.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":10802.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":10802.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":10802.40,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":10288.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":10288.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":10493.76,"methodology":"fee schedule"}]}]},{"description":"Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance (includes fluoroscopy, image documentation and report) ","code_information":[{"code":"43752","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":118.00,"maximum":413.01,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":125.82,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":125.82,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":125.82,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":125.82,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":147.50,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":413.01,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":129.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":129.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":129.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":129.80,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":118.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":118.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":373.58,"methodology":"fee schedule"}]}]},{"description":"NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION ","code_information":[{"code":"6083","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":29030.00,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":26940.96,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":24385.20,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":24385.20,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":24385.20,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":24385.20,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":29030.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":24385.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":24385.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":24385.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":24385.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":23224.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":23224.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":23688.48,"methodology":"fee schedule"}]}]},{"description":"Nerve graft (includes obtaining graft), single strand, arm or leg; up to 4 cm length ","code_information":[{"code":"64892","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3128.00,"maximum":6905.01,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":3331.23,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":3331.23,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":3331.23,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":3331.23,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":3910.00,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":6905.01,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":3440.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":3440.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":3440.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":3440.80,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":3128.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":3128.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6245.89,"methodology":"fee schedule"}]}]},{"description":"Open treatment of carpal scaphoid (navicular) fracture, includes internal fixation, when performed ","code_information":[{"code":"25628","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2523.00,"maximum":7415.64,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":3153.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7415.64,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2775.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":2775.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":2775.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":2775.30,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":2523.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":2523.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6707.78,"methodology":"fee schedule"}]}]},{"description":"Open treatment of scapular fracture (body, glenoid or acromion) includes internal fixation, when performed ","code_information":[{"code":"23585","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3447.00,"maximum":7415.64,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":3669.89,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":3669.89,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":3669.89,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":3669.89,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":4308.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7415.64,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":3791.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":3791.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":3791.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":3791.70,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":3447.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":3447.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6707.78,"methodology":"fee schedule"}]}]},{"description":"Opponensplasty; tendon transfer with graft (includes obtaining graft), each tendon ","code_information":[{"code":"26492","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1144.00,"maximum":3355.18,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":1430.00,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":3355.18,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":1144.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":1144.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":3034.92,"methodology":"fee schedule"}]}]},{"description":"ORGANIC MENTAL HEALTH CONDITIONS AND DISTURBANCES ","code_information":[{"code":"7573","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":8341.25,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":7741.73,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":7006.65,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":7006.65,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":7006.65,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":7006.65,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":8341.25,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":7006.65,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":7006.65,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":7006.65,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":7006.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":6673.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":6673.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":6806.46,"methodology":"fee schedule"}]}]},{"description":"OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE ","code_information":[{"code":"2533","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":5880.00,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":5457.20,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":4939.20,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":4939.20,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":4939.20,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":4939.20,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":5880.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":4939.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":4939.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":4939.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":4939.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":4704.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":4704.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":4798.08,"methodology":"fee schedule"}]}]},{"description":"OTHER GASTROENTERITIS, NAUSEA AND VOMITING ","code_information":[{"code":"2492","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":2977.50,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":2763.45,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2501.10,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2501.10,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2501.10,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2501.10,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":2977.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2501.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":2501.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":2501.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":2501.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":2382.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":2382.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2429.64,"methodology":"fee schedule"}]}]},{"description":"OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS ","code_information":[{"code":"4251","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":2611.25,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":2423.49,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2193.45,"methodology":"fee 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the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":2089.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":2089.00,"methodology":"fee 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Healthcare","plan_name":"STARKIDS","standard_charge_dollar":250.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":250.80,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":228.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":228.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":588.87,"methodology":"fee schedule"}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA ","code_information":[{"code":"5132","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":5738.75,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":5325.90,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":4820.55,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":4820.55,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":4820.55,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":4820.55,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":5738.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":4820.55,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":4820.55,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":4820.55,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":4820.55,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":4591.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":4591.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":4682.82,"methodology":"fee schedule"}]}]},{"description":"Sympathectomy; radial artery ","code_information":[{"code":"64821","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1144.00,"maximum":3355.18,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":1430.00,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":3355.18,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":1144.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":1144.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":3034.92,"methodology":"fee schedule"}]}]},{"description":"Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance ","code_information":[{"code":"32554","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":235.00,"maximum":651.18,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":250.60,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":250.60,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":250.60,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":250.60,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":293.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":651.18,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":258.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":258.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":258.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":258.50,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":235.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":235.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":589.02,"methodology":"fee schedule"}]}]},{"description":"Transmastoid antrotomy (simple mastoidectomy) ","code_information":[{"code":"69501","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2055.00,"maximum":6070.29,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2188.73,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2188.73,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2188.73,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2188.73,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":2568.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":6070.29,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2260.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":2260.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":2260.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":2260.50,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":2055.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":2055.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":5490.85,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) ","code_information":[{"code":"76705","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":88.00,"maximum":612.26,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":612.26,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":612.26,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":612.26,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":481.71,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":481.71,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":481.71,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":446.80,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":446.80,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":446.80,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":566.72,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":566.72,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":566.72,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":95.63,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":122.17,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":435.99,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":384.43,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":101.99,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":487.55,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":88.55,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":88.55,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":88.55,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":88.55,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":197.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":110.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":96.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":96.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":96.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":96.80,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":88.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":88.00,"methodology":"fee schedule"}]}]},{"description":"Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus ","code_information":[{"code":"50980","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1777.00,"maximum":5363.54,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":1892.16,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":1892.16,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":1892.16,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":1892.16,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":2221.25,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":5363.54,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1954.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1954.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1954.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1954.70,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":1777.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":1777.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":4851.57,"methodology":"fee schedule"}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY ","code_information":[{"code":"5111","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":6650.00,"payers_information":[{"payer_name":"Aetna Better 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Healthcare","plan_name":"STARKIDS","standard_charge_dollar":5586.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":5586.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":5320.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":5320.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":5426.40,"methodology":"fee schedule"}]}]},{"description":"Vesiculotomy; ","code_information":[{"code":"55600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":686.00,"maximum":2111.29,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":731.14,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":731.14,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":731.14,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":731.14,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":857.50,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":2111.29,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":754.60,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":754.60,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":754.60,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":754.60,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":686.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":686.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":1909.76,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) ","code_information":[{"code":"58661","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1987.00,"maximum":11899.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":9237.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":10005.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":11899.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":2483.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":5980.95,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2185.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":2185.70,"methodology":"fee 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reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross 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Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":17262.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":17262.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":17607.24,"methodology":"fee schedule"}]}]},{"description":"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE ","code_information":[{"code":"5814","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":3427.50,"payers_information":[{"payer_name":"Aetna Better 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Healthcare","plan_name":"STARKIDS","standard_charge_dollar":2879.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":2879.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":2742.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":2742.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2796.84,"methodology":"fee schedule"}]}]},{"description":"NERVOUS SYSTEM MALIGNANCY ","code_information":[{"code":"0413","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":6878.75,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":6383.60,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":5778.15,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":5778.15,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":5778.15,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":5778.15,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":6878.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":5778.15,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":5778.15,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":5778.15,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":5778.15,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":5503.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":5503.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":5613.06,"methodology":"fee schedule"}]}]},{"description":"Open treatment of acromioclavicular dislocation, acute or chronic; ","code_information":[{"code":"23550","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3319.00,"maximum":7415.64,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":3533.87,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":3533.87,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":3533.87,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":3533.87,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":4148.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7415.64,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":3650.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":3650.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":3650.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":3650.90,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":3319.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":3319.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6707.78,"methodology":"fee schedule"}]}]},{"description":"Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed; with proximal humeral prostheti ","code_information":[{"code":"23616","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10010.00,"maximum":19317.45,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":10657.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":10657.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":10657.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":10657.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":12512.50,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":19317.45,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":11011.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":11011.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":11011.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":11011.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":10010.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":10010.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":17473.51,"methodology":"fee schedule"}]}]},{"description":"Optic nerve decompression (eg, incision or fenestration of optic nerve sheath) ","code_information":[{"code":"67570","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1160.00,"maximum":4007.75,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":1235.83,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":1235.83,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":1235.83,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":1235.83,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":1450.00,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":4007.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1276.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1276.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1276.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1276.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":1160.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":1160.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":3625.19,"methodology":"fee schedule"}]}]},{"description":"Osteotomy, radius; distal third ","code_information":[{"code":"25350","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3562.00,"maximum":7415.64,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":3792.31,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":3792.31,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":3792.31,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":3792.31,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":4452.50,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7415.64,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":3918.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":3918.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":3918.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":3918.20,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":3562.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":3562.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6707.78,"methodology":"fee schedule"}]}]},{"description":"OTHER FEMALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES ","code_information":[{"code":"5182","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":6627.50,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":6150.72,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":5567.10,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":5567.10,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":5567.10,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":5567.10,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":6627.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":5567.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":5567.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":5567.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":5567.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":5302.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":5302.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":5408.04,"methodology":"fee schedule"}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES ","code_information":[{"code":"4841","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":8183.75,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":7595.55,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":6874.35,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":6874.35,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":6874.35,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":6874.35,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":8183.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":6874.35,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":6874.35,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":6874.35,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":6874.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":6547.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":6547.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":6677.94,"methodology":"fee schedule"}]}]},{"description":"OTHER SIGNIFICANT HIP AND FEMUR SURGERY ","code_information":[{"code":"3091","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":8846.25,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":8210.45,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":7430.85,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":7430.85,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":7430.85,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":7430.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":8846.25,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":7430.85,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":7430.85,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":7430.85,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":7430.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, 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charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":7077.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":7077.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":7218.54,"methodology":"fee schedule"}]}]},{"description":"Percutaneous skeletal fixation of humeral epicondylar fracture, medial or lateral, with manipulation ","code_information":[{"code":"24566","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":623.00,"maximum":1665.97,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":664.20,"methodology":"fee schedule"},{"payer_name":"Community Health Choice 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days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":3816.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":3816.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":3892.32,"methodology":"fee schedule"}]}]},{"description":"Impression and custom preparation; mandibular resection prosthesis ","code_information":[{"code":"21081","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":590.00,"maximum":6070.29,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":628.21,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":628.21,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":628.21,"methodology":"fee 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days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":6840.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":6840.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":6976.80,"methodology":"fee schedule"}]}]},{"description":"Labyrinthectomy; transcanal ","code_information":[{"code":"69905","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2055.00,"maximum":6070.29,"payers_information":[{"payer_name":"Community Health Choice 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may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":5915.00,"methodology":"case 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for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":11899.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":17479.00,"methodology":"case rate"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":2483.75,"methodology":"fee 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Healthplans","plan_name":"MEDICAID","standard_charge_dollar":1117.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":3511.23,"methodology":"fee schedule"}]}]},{"description":"LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA ","code_information":[{"code":"6912","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":8840.00,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":8204.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":7425.60,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":7425.60,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":7425.60,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":7425.60,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":8840.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":7425.60,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":7425.60,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":7425.60,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":7425.60,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":7072.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":7072.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":7213.44,"methodology":"fee schedule"}]}]},{"description":"MAJOR CHEST AND RESPIRATORY TRAUMA ","code_information":[{"code":"1354","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":11310.00,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":10496.26,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":9500.40,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":9500.40,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":9500.40,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":9500.40,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":11310.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":9500.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":9500.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":9500.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":9500.40,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":9048.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":9048.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":9228.96,"methodology":"fee schedule"}]}]},{"description":"MALNUTRITION, FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS ","code_information":[{"code":"4211","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":3568.75,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":3312.06,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2997.75,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2997.75,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2997.75,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2997.75,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":3568.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2997.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":2997.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":2997.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":2997.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":2855.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":2855.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2912.10,"methodology":"fee schedule"}]}]},{"description":"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS ","code_information":[{"code":"5322","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":2823.75,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":2620.67,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2371.95,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2371.95,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2371.95,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2371.95,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":2823.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2371.95,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":2371.95,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":2371.95,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":2371.95,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":2259.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":2259.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2304.18,"methodology":"fee schedule"}]}]},{"description":"MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES ","code_information":[{"code":"0434","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":64786.25,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":60122.74,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":54420.45,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":54420.45,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":54420.45,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":54420.45,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":64786.25,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":54420.45,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":54420.45,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":54420.45,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":54420.45,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":51829.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":51829.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":52865.58,"methodology":"fee schedule"}]}]},{"description":"Nasal/sinus endoscopy, surgical, with sphenoidotomy; ","code_information":[{"code":"31287","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1714.00,"maximum":7094.55,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":1825.73,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":1825.73,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":1825.73,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":1825.73,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":2142.50,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7094.55,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1885.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1885.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1885.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1885.40,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":1714.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":1714.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6417.34,"methodology":"fee schedule"}]}]},{"description":"NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION ","code_information":[{"code":"6031","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":15412.50,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":14302.96,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":12946.50,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":12946.50,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":12946.50,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":12946.50,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":15412.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":12946.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":12946.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":12946.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":12946.50,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":12330.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":12330.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":12576.60,"methodology":"fee schedule"}]}]},{"description":"Nerve graft (includes obtaining graft), head or neck; more than 4 cm length ","code_information":[{"code":"64886","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3572.00,"maximum":6905.01,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":3803.31,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":3803.31,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":3803.31,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":3803.31,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":4465.00,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":6905.01,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":3929.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":3929.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":3929.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":3929.20,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":3572.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":3572.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6245.89,"methodology":"fee schedule"}]}]},{"description":"NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS ","code_information":[{"code":"9523","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":22978.75,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":21325.25,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":19302.15,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":19302.15,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":19302.15,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":19302.15,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":22978.75,"methodology":"fee schedule"},{"payer_name":"Molina 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reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross 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Healthcare","plan_name":"CHIP","standard_charge_dollar":2185.05,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":2185.05,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":2185.05,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":2185.05,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":2081.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":2081.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2122.62,"methodology":"fee schedule"}]}]},{"description":"ALCOHOL ABUSE AND DEPENDENCE ","code_information":[{"code":"7752","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":3150.00,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":2923.23,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2646.00,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2646.00,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2646.00,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2646.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":3150.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2646.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":2646.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":2646.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":2646.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":2520.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":2520.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":2570.40,"methodology":"fee schedule"}]}]},{"description":"Amputation, metatarsal, with toe, single ","code_information":[{"code":"28810","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1144.00,"maximum":3355.18,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":1430.00,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":3355.18,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":1144.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":1144.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":3034.92,"methodology":"fee schedule"}]}]},{"description":"Anoscopy; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery ","code_information":[{"code":"46610","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":988.00,"maximum":2910.45,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":1052.72,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":1052.72,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":1052.72,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":1052.72,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":1235.00,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":2910.45,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1086.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1086.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1086.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1086.80,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":988.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":988.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":2632.64,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 ","code_information":[{"code":"22551","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7358.00,"maximum":13642.34,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":7833.93,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":7833.93,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":7833.93,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":7833.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":9197.50,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":13642.34,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":8093.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":8093.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":8093.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":8093.80,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":7358.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":7358.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":12340.12,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure) ","code_information":[{"code":"29860","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2523.00,"maximum":11899.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":9237.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":10005.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":11899.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":3153.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7415.64,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2775.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":2775.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":2775.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":2775.30,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":2523.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":2523.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6707.78,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, wrist, surgical; internal fixation for fracture or instability ","code_information":[{"code":"29847","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2523.00,"maximum":11899.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":9237.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":10005.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":11899.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":3153.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7415.64,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2775.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":2775.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":2775.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":2775.30,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":2523.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":2523.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6707.78,"methodology":"fee schedule"}]}]},{"description":"Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial AND lateral ","code_information":[{"code":"27333","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1144.00,"maximum":3355.18,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":1218.86,"methodology":"fee 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Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":1144.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":1144.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":3034.92,"methodology":"fee schedule"}]}]},{"description":"Biopsy of testis, needle (separate procedure) ","code_information":[{"code":"54500","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":857.00,"maximum":2945.39,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":913.02,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":913.02,"methodology":"fee schedule"},{"payer_name":"Community Health Choice 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necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 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charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":5481.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":5481.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":5590.62,"methodology":"fee schedule"}]}]},{"description":"MASTECTOMY PROCEDURES ","code_information":[{"code":"3621","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":8160.00,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":7573.03,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":6854.40,"methodology":"fee 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schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":6528.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":6528.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":6658.56,"methodology":"fee schedule"}]}]},{"description":"Multiple osteotomies with realignment on intramedullary rod, humeral shaft (Sofield type procedure) ","code_information":[{"code":"24410","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5061.00,"maximum":13642.34,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":5388.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":5388.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":5388.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":5388.34,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":6326.25,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":13642.34,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":5567.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":5567.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":5567.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":5567.10,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":5061.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":5061.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":12340.12,"methodology":"fee schedule"}]}]},{"description":"Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia ","code_information":[{"code":"31298","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1714.00,"maximum":7094.55,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":1825.73,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":1825.73,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":1825.73,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":1825.73,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":2142.50,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7094.55,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1885.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1885.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1885.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1885.40,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":1714.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":1714.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6417.34,"methodology":"fee schedule"}]}]},{"description":"NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER MAJOR PROCEDURE ","code_information":[{"code":"6311","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":11253.75,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":10444.42,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":9453.15,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":9453.15,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":9453.15,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":9453.15,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":11253.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":9453.15,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":9453.15,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":9453.15,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":9453.15,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":9003.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":9003.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":9183.06,"methodology":"fee schedule"}]}]},{"description":"NEONATE WITH ECMO ","code_information":[{"code":"5832","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":146742.50,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":136177.28,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":123263.70,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":123263.70,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":123263.70,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":123263.70,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":146742.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":123263.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":123263.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":123263.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":123263.70,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":117394.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":117394.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":119741.88,"methodology":"fee schedule"}]}]},{"description":"NON-ELECTIVE OR COMPLEX HIP JOINT REPLACEMENT ","code_information":[{"code":"3232","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":11428.75,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":10606.32,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":9600.15,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":9600.15,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":9600.15,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":9600.15,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":11428.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":9600.15,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":9600.15,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":9600.15,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":9600.15,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":9143.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":9143.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":9325.86,"methodology":"fee schedule"}]}]},{"description":"Open osteochondral autograft, talus (includes obtaining graftºs») ","code_information":[{"code":"28446","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3284.00,"maximum":7415.64,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":3497.24,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":3497.24,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":3497.24,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":3497.24,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":4105.00,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7415.64,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":3612.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":3612.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":3612.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":3612.40,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":3284.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":3284.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6707.78,"methodology":"fee schedule"}]}]},{"description":"Open treatment of medial malleolus fracture, includes internal fixation, when performed ","code_information":[{"code":"27766","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2523.00,"maximum":7415.64,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2686.34,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":3153.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":7415.64,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2775.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":2775.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":2775.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":2775.30,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":2523.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":2523.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6707.78,"methodology":"fee schedule"}]}]},{"description":"ORBIT AND EYE PROCEDURES ","code_information":[{"code":"0733","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":11833.75,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":10982.83,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":9940.35,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":9940.35,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":9940.35,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":9940.35,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":11833.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":9940.35,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":9940.35,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":9940.35,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":9940.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":9467.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":9467.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":9656.34,"methodology":"fee schedule"}]}]},{"description":"OTHER BACK AND NECK DISORDERS, FRACTURES AND INJURIES ","code_information":[{"code":"3471","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":4083.75,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":3790.13,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":3430.35,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":3430.35,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":3430.35,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":3430.35,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":4083.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":3430.35,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":3430.35,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":3430.35,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":3430.35,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":3267.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":3267.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":3332.34,"methodology":"fee schedule"}]}]},{"description":"OTHER DISORDERS OF NERVOUS SYSTEM ","code_information":[{"code":"0582","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":6842.50,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":6350.87,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":5747.70,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":5747.70,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":5747.70,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":5747.70,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":6842.50,"methodology":"fee schedule"},{"payer_name":"Molina 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reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":5474.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":5474.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":5583.48,"methodology":"fee schedule"}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES ","code_information":[{"code":"4842","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":9110.00,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":8454.38,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":7652.40,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":7652.40,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":7652.40,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":7652.40,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":9110.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":7652.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":7652.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":7652.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":7652.40,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":7288.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":7288.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":7433.76,"methodology":"fee schedule"}]}]},{"description":"Palatoplasty for cleft palate; secondary lengthening procedure ","code_information":[{"code":"42220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2055.00,"maximum":6070.29,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2188.73,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2188.73,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2188.73,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2188.73,"methodology":"fee 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schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":5490.85,"methodology":"fee schedule"}]}]},{"description":"Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); tarsal or metatarsal bone, except talus or calcaneus ","code_information":[{"code":"28122","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1144.00,"maximum":3355.18,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":1218.86,"methodology":"fee 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schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":3034.92,"methodology":"fee schedule"}]}]},{"description":"Percutaneous skeletal fixation of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation ","code_information":[{"code":"26650","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1144.00,"maximum":3355.18,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":1218.86,"methodology":"fee 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schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":3034.92,"methodology":"fee schedule"}]}]},{"description":"PERMANENT CARDIAC PACEMAKER IMPLANT WITH AMI, HEART FAILURE OR SHOCK ","code_information":[{"code":"1702","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12236.00,"maximum":15295.00,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":14194.60,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":12847.80,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":12847.80,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":12847.80,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":12847.80,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":15295.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":12847.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":12847.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":12847.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":12847.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":12860.93,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":12860.93,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":12860.93,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":12860.93,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":12860.93,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":12236.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":12236.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":12480.72,"methodology":"fee schedule"}]}]},{"description":"POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE ","code_information":[{"code":"7113","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":17156.25,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":15921.17,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":14411.25,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":14411.25,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":14411.25,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":14411.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":17156.25,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":14411.25,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":14411.25,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":14411.25,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":14411.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":13725.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":13725.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":13999.50,"methodology":"fee schedule"}]}]},{"description":"Radical resection of tumor (eg, sarcoma), soft tissue of back or flank; 5 cm or greater ","code_information":[{"code":"21936","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":857.00,"maximum":2945.39,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":913.02,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":913.02,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":913.02,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":913.02,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":1071.25,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":2945.39,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":942.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":942.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":942.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":942.70,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":857.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":857.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":2664.23,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, foot; complete, minimum of 3 views ","code_information":[{"code":"73630","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":34.00,"maximum":347.17,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":268.50,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":268.50,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":268.50,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":211.25,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":211.25,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":211.25,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":195.94,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":195.94,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":195.94,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":248.53,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":248.53,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":248.53,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":37.16,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":86.99,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":310.46,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":273.75,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":72.63,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":347.17,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":75.10,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":81.44,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":96.66,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":34.41,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":34.41,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":34.41,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":34.41,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":42.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":37.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":37.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":37.40,"methodology":"fee schedule"},{"payer_name":"Molina 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charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":14518.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":14518.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":14808.36,"methodology":"fee schedule"}]}]},{"description":"Capsulotomy, wrist (eg, contracture) ","code_information":[{"code":"25085","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1144.00,"maximum":3355.18,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice 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Healthplans","plan_name":"CHIP","standard_charge_dollar":3453.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":3453.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6707.78,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, elbow, surgical; with removal of loose body or foreign body ","code_information":[{"code":"29834","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1144.00,"maximum":11899.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":9237.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":10005.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":11899.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":1430.00,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":3355.18,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":1144.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":1144.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":3034.92,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, subtalar joint, surgical; with debridement ","code_information":[{"code":"29906","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1144.00,"maximum":6391.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":6391.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":5028.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":4665.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":5915.00,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":1218.86,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":1430.00,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":3355.18,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":1258.40,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":1144.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":1144.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":3034.92,"methodology":"fee schedule"}]}]},{"description":"Biliary endoscopy, percutaneous via T-tube or other tract; with removal of calculus/calculi ","code_information":[{"code":"47554","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1987.00,"maximum":10670.08,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2115.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":2483.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":10670.08,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2185.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":2185.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":2185.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":2185.70,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":1987.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":1987.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":9651.57,"methodology":"fee schedule"}]}]},{"description":"Biopsy of vulva or perineum (separate procedure); 1 lesion ","code_information":[{"code":"56605","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":47.00,"maximum":833.30,"payers_information":[{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":50.23,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":50.23,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":50.23,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":50.23,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":58.75,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":833.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":51.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":51.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":51.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":51.70,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":47.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":47.00,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":753.76,"methodology":"fee schedule"}]}]},{"description":"BREAST PROCEDURES EXCEPT MASTECTOMY ","code_information":[{"code":"3633","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":15471.25,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":14357.35,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":12995.85,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":12995.85,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":12995.85,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":12995.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":15471.25,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":12995.85,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":12995.85,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":12995.85,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":12995.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":12377.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":12377.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":12624.54,"methodology":"fee schedule"}]}]},{"description":"CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE ","code_information":[{"code":"1913","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1157.00,"maximum":8222.50,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":7630.82,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":6906.90,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":6906.90,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":6906.90,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":6906.90,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":8222.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":6906.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":6906.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":6906.90,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":6906.90,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":1157.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Texas Childrens Healthplans","plan_name":"CHIP","standard_charge_dollar":6578.00,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MEDICAID","standard_charge_dollar":6578.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":6709.56,"methodology":"fee schedule"}]}]},{"description":"CESAREAN SECTION WITHOUT STERILIZATION ","code_information":[{"code":"5401","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2135.00,"maximum":3824.00,"payers_information":[{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":2477.03,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":2241.75,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":2241.75,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":2241.75,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":2241.75,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":2668.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":2241.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":2241.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":2241.75,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":2241.75,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_dollar":3824.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3.  If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_dollar":3824.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3.  If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_dollar":3824.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3.  If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_dollar":3824.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3.  If billable gross charges exceed threshold of $125000.00, reimbursement will be the lesser of (a) 11% of billable gross charges, or (b) $2905 multiplied by the number of medically necessary days."},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_dollar":3824.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 3.  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