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charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":45.65,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":46.11,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":40.92,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":57.72,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":61.08,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":36.65,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":39.85,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":47.33,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":19.85,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":19.85,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":19.85,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":19.85,"methodology":"percent of total billed charges"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_percentage":28.10,"standard_charge_algorithm":"Reimbursement will be 28.1% of billable gross charges.","estimated_amount":42.91,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":26.00,"standard_charge_algorithm":"Reimbursement will be 26% of billable gross charges.","estimated_amount":39.70,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_percentage":31.91,"standard_charge_algorithm":"Reimbursement will be 31.91% of billable gross charges.","estimated_amount":48.72,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_percentage":31.91,"standard_charge_algorithm":"Reimbursement will be 31.91% of billable gross charges.","estimated_amount":48.72,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":29.01,"methodology":"percent of total billed charges"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","estimated_amount":53.44,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":41.23,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":31.61,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","estimated_amount":26.11,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":29.01,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":29.01,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_percentage":21.00,"standard_charge_algorithm":"Reimbursement will be 21% of billable gross charges.","estimated_amount":32.06,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":10.69,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":10.69,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":10.69,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":10.69,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":10.69,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":122.15,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":68.71,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":28.25,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC ","code_information":[{"code":"241","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":22148.77,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":13480.26,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":14340.70,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":15422.39,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12485.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11159.00,"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":13657.81,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":13657.81,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":13737.63,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":21991.04,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13521.23,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13521.23,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":13521.23,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":13521.23,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":13521.23,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":19803.82,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":13930.97,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":20099.97,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":16983.74,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":22148.77,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":13234.42,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":13234.42,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":22148.77,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":14477.28,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":13657.81,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":18984.36,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":20866.95,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":16012.94,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":13384.65,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":13343.61,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":14340.70,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":13930.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":13930.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":13930.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":13930.97,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":13930.97,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":14613.86,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":21169.61,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":21169.61,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":21169.61,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":14340.70,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":14340.70,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":14340.70,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":14340.70,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":14340.70,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":14340.70,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":14067.54,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13657.81,"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":13330.02,"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":13794.39,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15023.59,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":14067.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":14067.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":14067.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":14067.54,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":14067.54,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13521.23,"methodology":"fee schedule"}]}]},{"description":"Amputee wheelchair, detachable arms (desk or full length) swing away detachable footrests ","code_information":[{"code":"E1180","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":135.50,"maximum":283.45,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":139.45,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":145.18,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":138.27,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":138.27,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":138.27,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":138.27,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":138.27,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":138.27,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":138.27,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":138.27,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":200.49,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":138.27,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":138.27,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":138.27,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":142.42,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":192.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":283.45,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":135.50,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":145.18,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":146.57,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":146.57,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":146.57,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":146.57,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":146.57,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":145.18,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":214.32,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":214.32,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":200.49,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":145.18,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":145.18,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":145.18,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":145.18,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":145.18,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":145.18,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":138.27,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":138.96,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":139.65,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":179.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":142.42,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":142.42,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":142.42,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":142.42,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":142.42,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":138.96,"methodology":"fee schedule"}]}]},{"description":"ANAL AND STOMAL PROCEDURES WITH CC ","code_information":[{"code":"348","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":18617.26,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":11655.47,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":12399.44,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":13056.35,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12485.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11159.00,"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":11808.99,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":11808.99,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":11630.06,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":18617.26,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":11690.90,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":11690.90,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":11690.90,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":11690.90,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":11690.90,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":17123.04,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":12045.17,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":16758.40,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":14160.24,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":18466.60,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":11442.91,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":11442.91,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":18466.60,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":12517.53,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":11808.99,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":16414.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":17397.87,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":13350.83,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":11572.81,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":11125.27,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":12399.44,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":12045.17,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":12045.17,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":12045.17,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":12045.17,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":12045.17,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":12635.62,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":18303.93,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":18303.93,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":18303.93,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":12399.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":12399.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":12399.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":12399.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":12399.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":12399.44,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":12163.26,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":11808.99,"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":11525.57,"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":11927.08,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":12989.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":12163.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":12163.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":12163.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":12163.26,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":12163.26,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":11690.90,"methodology":"fee schedule"}]}]},{"description":"Androstenedione ","code_information":[{"code":"82157","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.60,"maximum":183.12,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":183.12,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":183.12,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":183.12,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":144.18,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":144.18,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":144.18,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":29.53,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":133.72,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":133.72,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":133.72,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":169.32,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":169.32,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":169.32,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":26.57,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":30.74,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":96.92,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":97.50,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":98.09,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":29.28,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":29.28,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":81.69,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":96.62,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":31.69,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":136.51,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":148.14,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":176.11,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":29.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":29.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":29.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":29.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":29.28,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":42.46,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":24.60,"methodology":"fee schedule"},{"payer_name":"Community Health Choice 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schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":80.52,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":30.74,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":31.04,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":31.04,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":31.04,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":31.04,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":31.04,"methodology":"fee schedule"},{"payer_name":"Shared 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schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":30.74,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":27.60,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":29.28,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":29.43,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":29.57,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":38.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":30.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":30.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":30.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":30.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":30.16,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":29.43,"methodology":"fee schedule"}]}]},{"description":"Aniseikonic lens, single vision ","code_information":[{"code":"V2118","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":84.23,"maximum":690.57,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":86.68,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":90.25,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":85.95,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":85.95,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":85.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":85.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":85.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":85.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":85.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":85.95,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":124.63,"methodology":"fee schedule"},{"payer_name":"Devoted 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schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":90.25,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":91.11,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":91.11,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":91.11,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":91.11,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":91.11,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":90.25,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":133.22,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":133.22,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":124.63,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":90.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":90.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":90.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":90.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":90.25,"methodology":"fee schedule"},{"payer_name":"Superior Health 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schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":1084.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":720.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":1599.00,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":720.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":720.50,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":720.50,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":2145.00,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":764.40,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":2145.00,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":819.00,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":826.80,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":826.80,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":826.80,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":826.80,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":826.80,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":819.00,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":1209.00,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":1209.00,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":1131.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":819.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":819.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":819.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":819.00,"methodology":"fee schedule"},{"payer_name":"Superior Health 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schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":803.40,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":803.40,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":803.40,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":783.90,"methodology":"fee schedule"}]}]},{"description":"APPENDIX PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"399","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":16766.07,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":10676.20,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":11357.66,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12485.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11159.00,"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":10816.82,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":10816.82,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":10708.65,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":10708.65,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":10708.65,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":10708.65,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":10708.65,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":15684.39,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":11033.16,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":14965.14,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":12645.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":16490.55,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":10481.50,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":10481.50,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":16490.55,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":11465.83,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":10816.82,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":15035.38,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":15536.19,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":11922.20,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":10600.48,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":9934.80,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":11357.66,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":11033.16,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":11033.16,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":11033.16,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":11033.16,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":11033.16,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":11574.00,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":16766.07,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":16766.07,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":16766.07,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":11357.66,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":11357.66,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":11357.66,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":11357.66,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":11357.66,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":11357.66,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":11141.32,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":10816.82,"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":10557.22,"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":10924.99,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":11898.50,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":11141.32,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":11141.32,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":11141.32,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":11141.32,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":11141.32,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":10708.65,"methodology":"fee 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schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":72.79,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":72.79,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":72.79,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":92.35,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":92.35,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":92.35,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":20.58,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":29.34,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":66.54,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":61.87,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":19.60,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":19.60,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":24.87,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":71.22,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":19.60,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":19.60,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":19.60,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":19.60,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":19.60,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":19.60,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":28.42,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":19.60,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":199.18,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":19.60,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":19.60,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":199.18,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":20.19,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":27.24,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":40.18,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":19.21,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":20.58,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":20.78,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":20.78,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":20.78,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of 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schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":20.19,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":20.19,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":20.19,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":20.19,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":19.70,"methodology":"fee schedule"}]}]},{"description":"Application of a modality to 1 or more areas; ultrasound, each 15 minutes ","code_information":[{"code":"97035","type":"CPT"}],"standard_charges":[{"modifiers":"GP|CQ","modifiers_description":"Services delivered under an outpatient physical therapy plan of care|Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant","setting":"outpatient","minimum":11.85,"maximum":24.80,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":12.20,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":12.70,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":12.10,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":12.10,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":12.10,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":12.10,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":12.10,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":12.10,"methodology":"fee schedule"},{"payer_name":"Cigna 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":32530.95,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12485.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11159.00,"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":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":28423.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":28423.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":28423.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":28423.79,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":28423.79,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":29817.11,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":43193.01,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":43193.01,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":43193.01,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":29259.78,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":29259.78,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":29259.78,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":29259.78,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":29259.78,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":29259.78,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":28702.45,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":27866.46,"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":27197.66,"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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","code_information":[{"code":"303500","type":"CDM"},{"code":"82374","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.10,"maximum":30.53,"gross_charge":591.78,"discounted_cash":591.78,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":30.53,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":30.53,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":30.53,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":24.04,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":24.04,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":24.04,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":4.92,"methodology":"fee 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schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":13.42,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":5.12,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":5.17,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":5.17,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":5.17,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":5.17,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":5.17,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":5.12,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":7.56,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":7.56,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":7.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":5.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":5.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":5.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":5.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":5.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":5.12,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":4.60,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":4.88,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":4.90,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":4.93,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":6.34,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":5.03,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":5.03,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":5.03,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":5.03,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":5.03,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":4.90,"methodology":"fee schedule"}]}]},{"description":"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC ","code_information":[{"code":"308","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3948.00,"maximum":17701.12,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":11271.62,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":11991.08,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":17626.81,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":11989.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10624.00,"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":11420.08,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":11420.08,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":15506.02,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16036.82,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":11305.88,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":11305.88,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":11305.88,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":11305.88,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":11305.88,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":16559.12,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":11648.48,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":16055.48,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":13566.29,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":17692.02,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":11066.06,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":11066.06,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":17692.02,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":12105.28,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":11420.08,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":15873.91,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":16668.13,"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":11191.68,"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":11991.08,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":11648.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":11648.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":11648.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":11648.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":11648.48,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":12219.49,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":17701.12,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":17701.12,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":17701.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":11991.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":11991.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":11991.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":11991.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":11991.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":11991.08,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":11762.68,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":11420.08,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6145.00,"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":11146.00,"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":6140.00,"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":3948.00,"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":11534.28,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":12562.09,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":11762.68,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":11762.68,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":11762.68,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":11762.68,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":11762.68,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":11305.88,"methodology":"fee schedule"}]}]},{"description":"Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); genomic sequence analysis panel, must include sequencing ","code_information":[{"code":"81413","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":573.20,"maximum":3658.40,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":3658.40,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":3658.40,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":3658.40,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":2880.49,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":2880.49,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":2880.49,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":589.87,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":2671.57,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":2671.57,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":2671.57,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":3382.80,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":3382.80,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":3382.80,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":614.14,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":1936.02,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":1947.72,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1959.41,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":584.90,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":584.90,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":1631.87,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1930.17,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":2739.35,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":2972.73,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3533.93,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":584.90,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":584.90,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":584.90,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":584.90,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":584.90,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":848.10,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":584.90,"methodology":"fee schedule"},{"payer_name":"Healthcare 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"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":8801.63,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":9232.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":9430.32,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11610.41,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6140.00,"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":3948.00,"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":12014.87,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":13085.50,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":12252.79,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":12252.79,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":12252.79,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":12252.79,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":12252.79,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":11776.95,"methodology":"fee 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Plan","plan_name":"MCRHMO","standard_charge_dollar":5.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":5.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":5.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":5.25,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":5.25,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":4.60,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":5.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":5.02,"methodology":"fee schedule"},{"payer_name":"Van Lang 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schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":18.44,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":18.44,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":18.44,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":17.99,"methodology":"fee schedule"}]}]},{"description":"CLSRE FMSTP CMPRSS GLD ","code_information":[{"code":"904291","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":2214.50,"discounted_cash":2214.50,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":985.45,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":985.45,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":985.45,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":777.29,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":777.29,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":777.29,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_percentage":6.63,"standard_charge_algorithm":"Reimbursement will be 6.63% of billable gross charges.","estimated_amount":146.82,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":719.71,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":719.71,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":719.71,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":912.37,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":912.37,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":912.37,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":666.56,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":620.06,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":662.14,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":668.78,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":593.49,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":837.08,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":885.80,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":531.48,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":577.98,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":686.50,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":287.88,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross 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be 26% of billable gross charges.","estimated_amount":575.77,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_percentage":31.91,"standard_charge_algorithm":"Reimbursement will be 31.91% of billable gross charges.","estimated_amount":706.65,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_percentage":31.91,"standard_charge_algorithm":"Reimbursement will be 31.91% of billable gross charges.","estimated_amount":706.65,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":420.75,"methodology":"percent of total billed charges"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross 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charges.","estimated_amount":155.01,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":155.01,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":155.01,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":155.01,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":1771.60,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":996.52,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":409.68,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"COAGULATION DISORDERS ","code_information":[{"code":"813","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3948.00,"maximum":22707.69,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":13757.25,"methodology":"fee 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":22678.98,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":11989.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10624.00,"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":13938.45,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":13938.45,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":19950.33,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20633.27,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13799.07,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":13799.07,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":13799.07,"methodology":"fee schedule"},{"payer_name":"Cigna 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schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":13506.36,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":22707.69,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":14774.76,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":13938.45,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":19374.45,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":21393.53,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":16417.03,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":13659.68,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":13680.34,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":14635.37,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":14217.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":14217.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":14217.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":14217.22,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":14217.22,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":14914.14,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":21604.60,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":21604.60,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":21604.60,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":14635.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":14635.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":14635.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":14635.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":14635.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":14635.37,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":14356.60,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13938.45,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6145.00,"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":13603.93,"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":6140.00,"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":3948.00,"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":14077.83,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15332.30,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":14356.60,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":14356.60,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":14356.60,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":14356.60,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":14356.60,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13799.07,"methodology":"fee schedule"}]}]},{"description":"Cochlear implant, external speech processor, component, replacement ","code_information":[{"code":"L8627","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8107.43,"maximum":66466.44,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":8343.21,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":8686.53,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":8272.89,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":8272.89,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":8272.89,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":8272.89,"methodology":"fee schedule"},{"payer_name":"Cigna 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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":20.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":20.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":20.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":20.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":20.32,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":29.46,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":17.07,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":17.07,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":17.07,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":17.07,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":20.32,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":56.45,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":21.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":20.32,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":20.32,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":20.93,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":28.24,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":18.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":41.66,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":18.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":18.70,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":18.70,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":55.88,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":19.91,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":55.88,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":21.34,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":21.54,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":21.54,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":21.54,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":21.54,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":21.54,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":21.34,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":31.50,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":31.50,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":29.46,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":21.34,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":21.34,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":21.34,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":21.34,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":21.34,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":21.34,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":19.55,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":20.32,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":20.42,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":20.52,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":26.42,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":20.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":20.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":20.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":20.93,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":20.93,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":20.42,"methodology":"fee schedule"}]}]},{"description":"COMPLICATIONS OF TREATMENT WITH CC ","code_information":[{"code":"920","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3948.00,"maximum":15529.61,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":9888.85,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":10520.06,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":15039.08,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":11989.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10624.00,"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":10019.10,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":10019.10,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":13229.64,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13682.51,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":9918.91,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":9918.91,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":9918.91,"methodology":"fee schedule"},{"payer_name":"Cigna 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"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":10219.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":10219.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":10219.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":10219.48,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":10219.48,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":10720.44,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":15529.61,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":15529.61,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":15529.61,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":10520.06,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":10520.06,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":10520.06,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":10520.06,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":10520.06,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":10520.06,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":10319.67,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":10019.10,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6145.00,"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":9778.64,"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":6140.00,"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":3948.00,"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":10119.29,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":11021.01,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":10319.67,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":10319.67,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":10319.67,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":10319.67,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":10319.67,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":9918.91,"methodology":"fee 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schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":176.30,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":798.49,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":798.49,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":798.49,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":1011.06,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":1011.06,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":1011.06,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":183.55,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":578.62,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":582.12,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":585.61,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":174.81,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":174.81,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":487.72,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":576.87,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":818.97,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":888.74,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1056.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":174.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":174.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":174.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":174.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":174.81,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":253.47,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":174.81,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":174.81,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":174.81,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":180.05,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":242.99,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":358.36,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":480.73,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":171.31,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":480.73,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":183.55,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":185.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":185.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":185.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":185.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":185.30,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":183.55,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":270.96,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":270.96,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":253.47,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":183.55,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":183.55,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":183.55,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":183.55,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":183.55,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":183.55,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":174.81,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":175.68,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":176.56,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":227.25,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":180.05,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":180.05,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":180.05,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":180.05,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":180.05,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":175.68,"methodology":"fee schedule"}]}]},{"description":"CONCUSSION WITHOUT CC/MCC ","code_information":[{"code":"090","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3948.00,"maximum":13718.87,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":8735.82,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":9293.43,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":12543.82,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":11989.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10624.00,"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":8850.88,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":8850.88,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":11034.60,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11412.33,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":8762.37,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":8762.37,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":8762.37,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":8762.37,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":8762.37,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":12833.78,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":9027.90,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":11411.90,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9642.64,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12575.12,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":8576.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":8576.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12575.12,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":9381.94,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":8850.88,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":12302.73,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":11847.36,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":9091.46,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":8673.87,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":7575.93,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":9293.43,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":9027.90,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":9027.90,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":9027.90,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":9027.90,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":9027.90,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":9470.44,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":13718.87,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":13718.87,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":13718.87,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":9293.43,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":9293.43,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":9293.43,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":9293.43,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":9293.43,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":9293.43,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":9116.41,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":8850.88,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6145.00,"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":8638.46,"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":6140.00,"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":3948.00,"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":8939.39,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":9735.97,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":9116.41,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":9116.41,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":9116.41,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":9116.41,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":9116.41,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":8762.37,"methodology":"fee schedule"}]}]},{"description":"Congo red, blood ","code_information":[{"code":"P2029","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4.85,"maximum":59.51,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":30.94,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":30.94,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":30.94,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":24.36,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":24.36,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":24.36,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":4.99,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":22.60,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":22.60,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":22.60,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":28.61,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":28.61,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":28.61,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":5.20,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":4.95,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":4.95,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":5.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":4.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":4.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":4.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":4.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":4.95,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":7.18,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":4.95,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":59.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":4.95,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":4.95,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":59.51,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":5.10,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":6.88,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":10.15,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":13.61,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":4.85,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":13.61,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":5.20,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":5.25,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":5.25,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":5.25,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":5.25,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":5.25,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":5.20,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":7.67,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":7.67,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":7.18,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":5.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":5.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":5.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":5.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":5.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":5.20,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":4.95,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":4.97,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":5.00,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":6.44,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":5.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":5.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":5.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":5.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":5.10,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":4.97,"methodology":"fee schedule"}]}]},{"description":"CONNECTOR IRR E-GTR ","code_information":[{"code":"103923","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":84.50,"discounted_cash":84.50,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":37.60,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":37.60,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":37.60,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":29.66,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":29.66,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":29.66,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_percentage":6.63,"standard_charge_algorithm":"Reimbursement will be 6.63% of billable gross charges.","estimated_amount":5.60,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":27.46,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":27.46,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":27.46,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":34.81,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":34.81,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":34.81,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":25.43,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":23.66,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":25.27,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":25.52,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":22.65,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":31.94,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":33.80,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":20.28,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":22.05,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":26.20,"methodology":"percent of total billed 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gross charges.","estimated_amount":245.40,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":100.89,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"Dimecaprol injection ","code_information":[{"code":"9039","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":58.61,"maximum":122.61,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":60.32,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":62.80,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":59.81,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":59.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":59.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":59.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":59.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":59.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":59.81,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":86.72,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":59.81,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":59.81,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":59.81,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":61.60,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":83.13,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":122.61,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":58.61,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":62.80,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":63.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":63.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":63.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":63.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":63.40,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":62.80,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":92.70,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":92.70,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":86.72,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":62.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":62.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":62.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":62.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":62.80,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":62.80,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":59.81,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":60.11,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":60.41,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":77.75,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":61.60,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":61.60,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":61.60,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":61.60,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":61.60,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":60.11,"methodology":"fee schedule"}]}]},{"description":"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC ","code_information":[{"code":"442","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3948.00,"maximum":14963.32,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":9528.26,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":10136.44,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":13650.54,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":11989.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10624.00,"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":9653.76,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":9653.76,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":12008.16,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12419.22,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":9557.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":9557.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":9557.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":9557.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":9557.22,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":13997.95,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":9846.83,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":12863.02,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":10868.78,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":14174.15,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":9354.49,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":9354.49,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":14174.15,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":10232.98,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":9653.76,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":13418.72,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":13353.85,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":10247.52,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":9460.68,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":8539.28,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":10136.44,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":9846.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":9846.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":9846.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":9846.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":9846.83,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":10329.52,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":14963.32,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":14963.32,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":14963.32,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":10136.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":10136.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":10136.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":10136.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":10136.44,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":10136.44,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":9943.37,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":9653.76,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6145.00,"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":9422.07,"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":6140.00,"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":3948.00,"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":9750.29,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":10619.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":9943.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":9943.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":9943.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":9943.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":9943.37,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":9557.22,"methodology":"fee schedule"}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITH MCC ","code_information":[{"code":"444","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3948.00,"maximum":24711.62,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":14750.34,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":15691.85,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":24535.74,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":11989.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10624.00,"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":14944.62,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":14944.62,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":21583.70,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":22322.55,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":14795.17,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":14795.17,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":14795.17,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":14795.17,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":14795.17,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":21669.70,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":15243.51,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":22425.75,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":18948.94,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":24711.62,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":14481.34,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":14481.34,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":24711.62,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":15841.30,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":14944.62,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":20773.02,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":23281.47,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":17865.81,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":14645.73,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":14887.61,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":15691.85,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":15243.51,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":15243.51,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":15243.51,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":15243.51,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":15243.51,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":15990.74,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":23164.16,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":23164.16,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":23164.16,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":15691.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":15691.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":15691.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":15691.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":15691.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":15691.85,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":15392.96,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":14944.62,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6145.00,"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":14585.95,"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":6140.00,"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":3948.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":10817.69,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":11989.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10624.00,"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":8042.85,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":8042.85,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":9516.14,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9841.90,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":7962.43,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":7962.43,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":7962.43,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":7962.43,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":7962.43,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":11662.14,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":8203.71,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":9951.47,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":8408.63,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":10965.83,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":7793.53,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":7793.53,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":10965.83,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":8525.43,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":8042.85,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":11179.57,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":10331.20,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":7927.99,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":7882.00,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":6606.41,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":8445.00,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":8203.71,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":8203.71,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":8203.71,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":8203.71,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":8203.71,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":8605.85,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":12466.42,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":12466.42,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":12466.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":8445.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":8445.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":8445.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":8445.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":8445.00,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":8445.00,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":8284.14,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":8042.85,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6145.00,"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":7849.83,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6140.00,"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":3948.00,"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":8123.28,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":8847.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":8284.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":8284.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":8284.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":8284.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":8284.14,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":7962.43,"methodology":"fee 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schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":235.86,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":348.18,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":348.18,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":325.72,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":235.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":235.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":235.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":235.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":235.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":235.86,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":224.63,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":225.76,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":226.88,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":292.02,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":231.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":231.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":231.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":231.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":231.37,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":225.76,"methodology":"fee schedule"}]}]},{"description":"EGD DILATION W/GUIDEWIRE ","code_information":[{"code":"91675","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":8345.59,"discounted_cash":8345.59,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_percentage":6.63,"standard_charge_algorithm":"Reimbursement will be 6.63% of billable gross charges.","estimated_amount":553.31,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross 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MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":1084.93,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":1084.93,"methodology":"percent of total billed charges"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_percentage":28.10,"standard_charge_algorithm":"Reimbursement will be 28.1% of billable gross charges.","estimated_amount":2345.11,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_percentage":31.91,"standard_charge_algorithm":"Reimbursement will be 31.91% of billable gross charges.","estimated_amount":2663.08,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_percentage":31.91,"standard_charge_algorithm":"Reimbursement will be 31.91% of billable gross charges.","estimated_amount":2663.08,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":1585.66,"methodology":"percent of total billed charges"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","estimated_amount":2920.96,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":2253.31,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":1585.66,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":1585.66,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_percentage":21.00,"standard_charge_algorithm":"Reimbursement will be 21% of billable gross charges.","estimated_amount":1752.57,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":584.19,"methodology":"percent of total billed charges"},{"payer_name":"Superior 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","code_information":[{"code":"104560","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":5000.00,"discounted_cash":5000.00,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_percentage":6.63,"standard_charge_algorithm":"Reimbursement will be 6.63% of billable gross charges.","estimated_amount":331.50,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":1505.00,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":1400.00,"methodology":"percent of total billed 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charges.","estimated_amount":1368.20,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_percentage":21.00,"standard_charge_algorithm":"Reimbursement will be 21% of billable gross charges.","estimated_amount":1512.22,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":504.07,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":504.07,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":504.07,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":504.07,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":504.07,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":5760.82,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":3240.46,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":1332.19,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"ENDOCRINE DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"645","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3948.00,"maximum":12826.06,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":8167.30,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":8688.62,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":11281.51,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":11989.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10624.00,"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":8274.88,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":8274.88,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":9924.16,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10263.88,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":8192.13,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":8192.13,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":8192.13,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":8192.13,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":8192.13,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":11998.57,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":8440.37,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":10370.83,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":8762.97,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":11427.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":8018.35,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":8018.35,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":11427.93,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":8771.37,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":8274.88,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":11502.08,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":10766.56,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":8262.07,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":8109.38,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":6884.80,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":8688.62,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":8440.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":8440.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":8440.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":8440.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":8440.37,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":8854.12,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":12826.06,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":12826.06,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":12826.06,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":8688.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":8688.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":8688.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":8688.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":8688.62,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":8688.62,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":8523.12,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":8274.88,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6145.00,"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":8076.28,"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":6140.00,"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":3948.00,"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":8357.62,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":9102.36,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":8523.12,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":8523.12,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":8523.12,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":8523.12,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":8523.12,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":8192.13,"methodology":"fee schedule"}]}]},{"description":"Enlargement of ocular prosthesis ","code_information":[{"code":"V2625","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":440.63,"maximum":3612.47,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":453.44,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":472.10,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":449.62,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":449.62,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":449.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":449.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":449.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":449.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":449.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":449.62,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":651.95,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":449.62,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":3612.47,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":449.62,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":449.62,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":3612.47,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":463.11,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":624.97,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":921.72,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":440.63,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":472.10,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":476.60,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":476.60,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":476.60,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":476.60,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":476.60,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":472.10,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":696.91,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":696.91,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":651.95,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":472.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":472.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":472.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":472.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":472.10,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":472.10,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":449.62,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":451.87,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":454.12,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":584.51,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":463.11,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":463.11,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":463.11,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":463.11,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":463.11,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":451.87,"methodology":"fee schedule"}]}]},{"description":"EPINEPHRINE 5MG/NS 250ML ","code_information":[{"code":"60083","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":187.34,"discounted_cash":187.34,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":83.37,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":83.37,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":83.37,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":65.76,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":65.76,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":65.76,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_percentage":6.63,"standard_charge_algorithm":"Reimbursement will be 6.63% of billable gross charges.","estimated_amount":12.42,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":60.89,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":60.89,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":60.89,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":77.18,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":77.18,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":77.18,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":56.39,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":52.46,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":56.01,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":56.58,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":50.21,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":70.81,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":74.94,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":44.96,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":48.90,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":58.08,"methodology":"percent of total billed 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charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":20.44,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":20.44,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":20.44,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":25.91,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":25.91,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":25.91,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":18.93,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":17.61,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":18.80,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":18.99,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":16.85,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":23.77,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":25.15,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":15.09,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":16.41,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":19.49,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":8.17,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":8.17,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":8.17,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":8.17,"methodology":"percent of total billed charges"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_percentage":28.10,"standard_charge_algorithm":"Reimbursement will be 28.1% of billable gross charges.","estimated_amount":17.67,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":26.00,"standard_charge_algorithm":"Reimbursement will be 26% of billable gross charges.","estimated_amount":16.35,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_percentage":31.91,"standard_charge_algorithm":"Reimbursement will be 31.91% of billable gross charges.","estimated_amount":20.07,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_percentage":31.91,"standard_charge_algorithm":"Reimbursement will be 31.91% of billable gross charges.","estimated_amount":20.07,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":11.95,"methodology":"percent of total billed charges"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","estimated_amount":22.01,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":16.98,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":13.02,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","estimated_amount":10.75,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":11.95,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":11.95,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_percentage":21.00,"standard_charge_algorithm":"Reimbursement will be 21% of billable gross charges.","estimated_amount":13.20,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":4.40,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":4.40,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":4.40,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":4.40,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":4.40,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":50.30,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":28.30,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":11.63,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC ","code_information":[{"code":"392","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3087.00,"maximum":13706.00,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":8176.75,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":8698.67,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":12215.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7.  If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":11658.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7.  If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9610.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7.  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":8284.45,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":8284.45,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":11468.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7.  If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13706.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 7.  If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":8201.61,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":8201.61,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":8201.61,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":8201.61,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":8201.61,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":12012.46,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":8450.14,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":3087.00,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":8777.59,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":11447.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":8027.63,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":8027.63,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":11447.00,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":8781.52,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":8284.45,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":11515.39,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":10784.53,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":8275.86,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":8118.76,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":6896.29,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":8698.67,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":8450.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":8450.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":8450.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":8450.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":8450.14,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":8864.36,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":12840.90,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":12840.90,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":12840.90,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":8698.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":8698.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":8698.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":8698.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":8698.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":8698.67,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":8532.99,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":8284.45,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6145.00,"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":8085.63,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6140.00,"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":3948.00,"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":8367.30,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":9112.90,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":8532.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":8532.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":8532.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":8532.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":8532.99,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":8201.61,"methodology":"fee schedule"}]}]},{"description":"Estrogens; fractionated ","code_information":[{"code":"82671","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.13,"maximum":202.05,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":202.05,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":202.05,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":202.05,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":159.08,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":159.08,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":159.08,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":32.57,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":147.55,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":147.55,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":147.55,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":186.83,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":186.83,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":186.83,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":29.30,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":33.91,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":106.91,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":107.56,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":108.20,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":32.30,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":32.30,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":90.12,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":106.59,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":34.96,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":150.76,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":163.60,"methodology":"fee 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Healthcare","plan_name":"STARPLUS","standard_charge_dollar":12.10,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":37.76,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":13.46,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":37.76,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":14.42,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":14.55,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":14.55,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":14.55,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":14.55,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":14.55,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":14.42,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":21.28,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":21.28,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":19.91,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":14.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":14.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":14.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":14.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":14.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":14.42,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":12.65,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":13.73,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13.80,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":13.87,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":17.85,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":14.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":14.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":14.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":14.14,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":14.14,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13.80,"methodology":"fee schedule"}]}]},{"description":"EXPANDER BRST TISS 300C ","code_information":[{"code":"600649","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":15994.00,"discounted_cash":15994.00,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_percentage":6.63,"standard_charge_algorithm":"Reimbursement will be 6.63% of billable gross charges.","estimated_amount":1060.40,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":6045.73,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":6397.60,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":2079.22,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":2079.22,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":2079.22,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":2079.22,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":4318.38,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":3038.86,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":3038.86,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_percentage":21.00,"standard_charge_algorithm":"Reimbursement will be 21% of billable gross charges.","estimated_amount":3358.74,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":12795.20,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":7197.30,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":2958.89,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC ","code_information":[{"code":"981","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":69745.58,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":37067.95,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":39433.99,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 8. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":44691.43,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12485.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11159.00,"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":37556.18,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":37556.18,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":39809.29,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":63726.24,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":37180.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":37180.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":37180.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":37180.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":37180.62,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":54456.46,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":38307.30,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":63294.00,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":53481.12,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":69745.58,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":36391.94,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":36391.94,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":69745.58,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":39809.55,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":37556.18,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":52203.09,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":65709.18,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":50424.11,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":36805.06,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":42018.50,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":39433.99,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 8. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":38307.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":38307.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":38307.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":38307.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":38307.30,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":40185.11,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":58212.08,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":58212.08,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":58212.08,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":39433.99,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":39433.99,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":39433.99,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":39433.99,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":39433.99,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":39433.99,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":38682.87,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":37556.18,"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":36654.83,"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":37931.74,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":41311.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":38682.87,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":38682.87,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":38682.87,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":38682.87,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":38682.87,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":37180.62,"methodology":"fee schedule"}]}]},{"description":"External recharging system for battery for use with cochlear implant or auditory osseointegrated device, replacement only, each ","code_information":[{"code":"L8625","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":184.65,"maximum":1798.49,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":225.75,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health","plan_name":"MGMCD","standard_charge_dollar":199.42,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":235.04,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":223.85,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":223.85,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":223.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":223.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":223.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":223.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":223.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":223.85,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":324.58,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_dollar":184.65,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_dollar":184.65,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_dollar":184.65,"methodology":"fee schedule"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_dollar":184.65,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":223.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":1798.49,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCD","standard_charge_dollar":230.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":223.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":223.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":1798.49,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":230.57,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":311.15,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"CHIP","standard_charge_dollar":202.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":458.89,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STAR","standard_charge_dollar":202.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARKIDS","standard_charge_dollar":202.40,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"STARPLUS","standard_charge_dollar":202.40,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":219.37,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":235.04,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":237.28,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":237.28,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":237.28,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":237.28,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":237.28,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":235.04,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":346.97,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":346.97,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":324.58,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":235.04,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":235.04,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":235.04,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":235.04,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":235.04,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":235.04,"methodology":"fee schedule"},{"payer_name":"Texas Childrens Healthplans","plan_name":"MCD","standard_charge_dollar":211.60,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":223.85,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":224.97,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MGMCD","standard_charge_dollar":188.34,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":226.09,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":291.00,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":230.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":230.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":230.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":230.57,"methodology":"fee 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days."},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":11076.83,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":11076.83,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":14888.83,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15398.50,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":10966.06,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":10966.06,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":10966.06,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":10966.06,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":10966.06,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":16061.40,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":11298.37,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":15435.09,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":13042.09,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":17008.40,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":10733.45,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":10733.45,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":17008.40,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":11741.44,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":11076.83,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":15396.79,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":16024.07,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":12296.60,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":10855.29,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":10246.78,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":11630.67,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":11298.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":11298.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":11298.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":11298.37,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":11298.37,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":11852.21,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":17169.09,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":17169.09,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":17169.09,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":11630.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":11630.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":11630.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":11630.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":11630.67,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":11630.67,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":11409.13,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":11076.83,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6145.00,"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":10810.99,"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":6140.00,"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":3948.00,"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":11187.60,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":12184.51,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":11409.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":11409.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":11409.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":11409.13,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":11409.13,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":10966.06,"methodology":"fee schedule"}]}]},{"description":"HEART FAILURE AND SHOCK WITHOUT CC/MCC ","code_information":[{"code":"293","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4523.00,"maximum":14421.00,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":6495.19,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":6909.78,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":8658.55,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":11989.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10624.00,"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":6580.74,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":6580.74,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":7616.79,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7877.52,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":6514.93,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":6514.93,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":6514.93,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":6514.93,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":6514.93,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":9542.07,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":6712.35,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":7308.84,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":6175.70,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":8053.83,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":6376.74,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":6376.74,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":8053.83,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":6975.58,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":6580.74,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":9147.23,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":7587.73,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":5822.69,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":6449.13,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":4852.06,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":6909.78,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":6712.35,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":6712.35,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":6712.35,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":6712.35,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":6712.35,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":7041.39,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":10200.15,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":10200.15,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":10200.15,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":6909.78,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":6909.78,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":6909.78,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":6909.78,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":6909.78,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":6909.78,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":6778.16,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":6580.74,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14421.00,"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":6422.80,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":10703.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":13650.00,"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":9858.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":6646.55,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":7238.81,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":6778.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":6778.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":6778.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":6778.16,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":6778.16,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":6514.93,"methodology":"fee schedule"}]}]},{"description":"Heavy duty wheelchair, fixed full length arms, elevating legrest ","code_information":[{"code":"E1295","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":162.42,"maximum":339.75,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":167.14,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":174.02,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":165.73,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":165.73,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":165.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":165.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":165.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":165.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":165.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":165.73,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":240.31,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":165.73,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":165.73,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":165.73,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":170.70,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":230.36,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":339.75,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":162.42,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":174.02,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":175.67,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":175.67,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":175.67,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":175.67,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":175.67,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":174.02,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":256.88,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":256.88,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":240.31,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":174.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":174.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":174.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":174.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":174.02,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":174.02,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":165.73,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":166.56,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":167.39,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":215.45,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":170.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":170.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":170.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":170.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":170.70,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":166.56,"methodology":"fee schedule"}]}]},{"description":"Heel, counter, leather reinforced ","code_information":[{"code":"L3440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":88.47,"maximum":725.34,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":91.05,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":94.79,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":90.28,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":90.28,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":90.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":90.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":90.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":90.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":90.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":90.28,"methodology":"fee schedule"},{"payer_name":"Community Health 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charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":47.39,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":37.38,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":37.38,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":37.38,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_percentage":6.63,"standard_charge_algorithm":"Reimbursement will be 6.63% of billable gross charges.","estimated_amount":7.06,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":34.61,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":34.61,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":34.61,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":43.88,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":43.88,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":43.88,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":32.06,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":29.82,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":31.84,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":32.16,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":28.54,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":40.26,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":42.60,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":25.56,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":27.80,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":33.02,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":13.85,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":13.85,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":13.85,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":13.85,"methodology":"percent of total billed charges"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_percentage":28.10,"standard_charge_algorithm":"Reimbursement will be 28.1% of billable gross charges.","estimated_amount":29.93,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":26.00,"standard_charge_algorithm":"Reimbursement will be 26% of billable gross charges.","estimated_amount":27.69,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_percentage":31.91,"standard_charge_algorithm":"Reimbursement will be 31.91% of billable gross charges.","estimated_amount":33.98,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_percentage":31.91,"standard_charge_algorithm":"Reimbursement will be 31.91% of billable gross charges.","estimated_amount":33.98,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":20.23,"methodology":"percent of total billed charges"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","estimated_amount":37.27,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":28.75,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":22.05,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","estimated_amount":18.21,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":20.23,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":20.23,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_percentage":21.00,"standard_charge_algorithm":"Reimbursement will be 21% of billable gross charges.","estimated_amount":22.36,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":7.46,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":7.46,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":7.46,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":7.46,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":7.46,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":85.20,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":47.92,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":19.70,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITH MCC ","code_information":[{"code":"193","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3948.00,"maximum":25897.00,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":12084.41,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":12855.76,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":25897.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 12.  If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":21958.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 12.  If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":18914.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 12.  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":12243.58,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":12243.58,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":18923.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 12.  If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25001.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 12.  If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":12121.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":12121.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":12121.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":12121.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":12121.14,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":17753.19,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":12488.45,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":15435.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":14823.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":19332.13,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":11864.03,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":11864.03,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":19332.13,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":12978.19,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":12243.58,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":17018.58,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":18213.31,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":13976.59,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":11998.71,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":11646.72,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":12855.76,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":12488.45,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":12488.45,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":12488.45,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":12488.45,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":12488.45,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13100.63,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":18977.55,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":18977.55,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":18977.55,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":12855.76,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":12855.76,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":12855.76,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":12855.76,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":12855.76,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":12855.76,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":12610.89,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":12243.58,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6145.00,"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":11949.73,"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":6140.00,"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":3948.00,"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":12366.02,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":13467.94,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":12610.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":12610.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":12610.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":12610.89,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":12610.89,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":12121.14,"methodology":"fee schedule"}]}]},{"description":"SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC ","code_information":[{"code":"451","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10579.00,"maximum":45268.69,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":28188.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":28188.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":33224.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":22178.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":22178.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":26139.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":24937.87,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_dollar":20578.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_dollar":20578.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_dollar":24252.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_dollar":26092.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_dollar":26092.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_dollar":30753.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":26529.65,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12485.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11159.00,"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":25266.33,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":25266.33,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":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":25013.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":25013.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":25013.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":25013.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":25013.67,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":36636.18,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":25771.66,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":41081.26,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":34712.16,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":45268.69,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":24483.07,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":24483.07,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":45268.69,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":26782.31,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":25266.33,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":35120.20,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":42648.84,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":32727.99,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":24761.00,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":27272.30,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":26529.65,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":25771.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":25771.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":25771.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":25771.66,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":25771.66,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":27034.97,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":39162.81,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":39162.81,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":39162.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":26529.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":26529.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":26529.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":26529.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":26529.65,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":26529.65,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":26024.32,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":25266.33,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":34682.00,"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":24659.94,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":25867.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":32827.00,"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":23707.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":25518.99,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":27792.96,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":26024.32,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":26024.32,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":26024.32,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":26024.32,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":26024.32,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":25013.67,"methodology":"fee schedule"}]}]},{"description":"Sitz type bath or equipment, portable, used with or without commode, with faucet attachment/s ","code_information":[{"code":"E0161","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":26.45,"maximum":55.33,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":27.22,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":28.34,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":26.99,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":26.99,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":26.99,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":26.99,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":26.99,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":26.99,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":26.99,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":26.99,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":39.14,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":26.99,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":26.99,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":26.99,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":27.80,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":37.52,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":55.33,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":26.45,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":28.34,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":28.61,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":28.61,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":28.61,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":28.61,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":28.61,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":28.34,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":41.83,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":41.83,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":39.14,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":28.34,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":28.34,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":28.34,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":28.34,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":28.34,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":28.34,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":26.99,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":27.12,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":27.26,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":35.09,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":27.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":27.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":27.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":27.80,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":27.80,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":27.12,"methodology":"fee schedule"}]}]},{"description":"SKIN DEBRIDEMENT WITH CC ","code_information":[{"code":"571","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":24569.32,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":14679.82,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":15616.83,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":15838.85,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12485.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11159.00,"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":14873.17,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":14873.17,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":14108.60,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":22584.87,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":14724.44,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":14724.44,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":14724.44,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":14724.44,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":14724.44,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":21566.10,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":15170.63,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":22296.61,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":18839.83,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":24569.32,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":14412.10,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":14412.10,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":24569.32,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":15765.56,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":14873.17,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":20673.71,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":23147.41,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":17762.93,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":14575.71,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":14801.88,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":15616.83,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":15170.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":15170.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":15170.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":15170.63,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":15170.63,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":15914.29,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":23053.41,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":23053.41,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":23053.41,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":15616.83,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":15616.83,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":15616.83,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":15616.83,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":15616.83,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":15616.83,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":15319.37,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":14873.17,"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":14516.21,"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":15021.90,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":16360.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":15319.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":15319.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":15319.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":15319.37,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":15319.37,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":14724.44,"methodology":"fee schedule"}]}]},{"description":"SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC ","code_information":[{"code":"575","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":29288.65,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":17018.59,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":18104.89,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":17076.59,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12485.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11159.00,"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":17242.75,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":17242.75,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":15211.13,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":24349.79,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":17070.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":17070.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":17070.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":17070.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":17070.32,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":25001.99,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":17587.60,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":26579.40,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":22458.63,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":29288.65,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":16708.22,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":16708.22,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":29288.65,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":18277.32,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":17242.75,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":23967.42,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":27593.63,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":21174.88,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":16897.90,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":17645.07,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":18104.89,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":17587.60,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":17587.60,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":17587.60,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":17587.60,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":17587.60,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":18449.74,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":26726.26,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":26726.26,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":26726.26,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":18104.89,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":18104.89,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":18104.89,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":18104.89,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":18104.89,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":18104.89,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":17760.03,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":17242.75,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16828.92,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":17415.18,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":18967.03,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":17760.03,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":17760.03,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":17760.03,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":17760.03,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":17760.03,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":17070.32,"methodology":"fee schedule"}]}]},{"description":"Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 inches, any depth ","code_information":[{"code":"E2624","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":365.98,"maximum":765.57,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":376.62,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":392.12,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":373.45,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":373.45,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":373.45,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":373.45,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":373.45,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":373.45,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":373.45,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":373.45,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":541.50,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":373.45,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":373.45,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":373.45,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":384.65,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":519.10,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":765.57,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":365.98,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":392.12,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":395.86,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":395.86,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":395.86,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":395.86,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":395.86,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":392.12,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":578.85,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":578.85,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":541.50,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":392.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":392.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":392.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":392.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":392.12,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":392.12,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":373.45,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":375.32,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":377.18,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":485.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":384.65,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":384.65,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":384.65,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":384.65,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":384.65,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":375.32,"methodology":"fee schedule"}]}]},{"description":"SKIN ULCERS WITH MCC ","code_information":[{"code":"592","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3948.00,"maximum":30164.45,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":17452.62,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":18566.61,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":24868.94,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":11989.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10624.00,"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":17682.49,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":17682.49,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":21876.80,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":22625.68,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":17505.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":17505.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":17505.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":17505.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":17505.67,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":25639.61,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":18036.14,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":27374.19,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":23130.19,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":30164.45,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":17134.33,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":17134.33,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":30164.45,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":18743.44,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":17682.49,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":24578.66,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":28418.74,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":21808.06,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":17328.84,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":18172.70,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":18566.61,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":18036.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":18036.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":18036.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":18036.14,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":18036.14,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":18920.26,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":27407.86,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":27407.86,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":27407.86,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":18566.61,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":18566.61,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":18566.61,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":18566.61,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":18566.61,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":18566.61,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":18212.96,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":17682.49,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6145.00,"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":17258.11,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6140.00,"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":3948.00,"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":17859.31,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":19450.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":18212.96,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":18212.96,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":18212.96,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":18212.96,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":18212.96,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":17505.67,"methodology":"fee schedule"}]}]},{"description":"SLEEVE LAPSCP 11MM 100MM ","code_information":[{"code":"600011","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":1432.50,"discounted_cash":1432.50,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":637.46,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":637.46,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":637.46,"methodology":"percent of total billed 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charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_percentage":31.91,"standard_charge_algorithm":"Reimbursement will be 31.91% of billable gross charges.","estimated_amount":168.18,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_percentage":31.91,"standard_charge_algorithm":"Reimbursement will be 31.91% of billable gross charges.","estimated_amount":168.18,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":100.14,"methodology":"percent of total billed charges"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","estimated_amount":184.46,"methodology":"percent of total billed charges"},{"payer_name":"Molina 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charges"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":100.14,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_percentage":21.00,"standard_charge_algorithm":"Reimbursement will be 21% of billable gross charges.","estimated_amount":110.68,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":36.89,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":36.89,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":36.89,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":36.89,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":36.89,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":421.63,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":237.17,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":97.50,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"SODIUM CHLORIDE 4MEQ/ML ","code_information":[{"code":"834230","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":76.99,"discounted_cash":76.99,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% 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of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":25.02,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":31.72,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":31.72,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":31.72,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":23.17,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":21.56,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":23.02,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":23.25,"methodology":"percent of total billed 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charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":20.09,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":23.87,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":10.01,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross 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26% of billable gross charges.","estimated_amount":20.02,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_percentage":31.91,"standard_charge_algorithm":"Reimbursement will be 31.91% of billable gross charges.","estimated_amount":24.57,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_percentage":31.91,"standard_charge_algorithm":"Reimbursement will be 31.91% of billable gross charges.","estimated_amount":24.57,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":14.63,"methodology":"percent of total billed charges"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross 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charges.","estimated_amount":5.39,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":5.39,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":5.39,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":5.39,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":61.59,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":34.65,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":14.24,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"SOFT TISSUE PROCEDURES WITH CC ","code_information":[{"code":"501","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4779.00,"maximum":26184.48,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":15480.26,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":16468.36,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":16988.46,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12485.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11159.00,"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":15684.15,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":15684.15,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":15132.62,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":24224.12,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":15527.31,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":15527.31,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":15527.31,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":15527.31,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":15527.31,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":22742.02,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":15997.83,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":23762.37,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":20078.34,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":26184.48,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":15197.94,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":15197.94,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":26184.48,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":16625.20,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":15684.15,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":21800.97,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":24669.10,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":18930.65,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":15370.47,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":15774.95,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":16468.36,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":15997.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":15997.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":15997.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":15997.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":15997.83,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":16782.04,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":24310.43,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":24310.43,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":24310.43,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":16468.36,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":16468.36,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":16468.36,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":16468.36,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":16468.36,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":16468.36,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":16154.67,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":15684.15,"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":15307.73,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  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charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":30.39,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":30.39,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":30.39,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":38.52,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":38.52,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":38.52,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":28.14,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":26.18,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":27.96,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":28.24,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":25.06,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":35.34,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":37.40,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":22.44,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":24.40,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":28.98,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":12.15,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":12.15,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":12.15,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":12.15,"methodology":"percent of total billed charges"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_percentage":28.10,"standard_charge_algorithm":"Reimbursement will be 28.1% of billable gross charges.","estimated_amount":26.27,"methodology":"percent of total billed charges"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_percentage":26.00,"standard_charge_algorithm":"Reimbursement will be 26% of billable gross charges.","estimated_amount":24.31,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_percentage":31.91,"standard_charge_algorithm":"Reimbursement will be 31.91% of billable gross charges.","estimated_amount":29.84,"methodology":"percent of total billed charges"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_percentage":31.91,"standard_charge_algorithm":"Reimbursement will be 31.91% of billable gross charges.","estimated_amount":29.84,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":17.77,"methodology":"percent of total billed charges"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","estimated_amount":32.73,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":25.25,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross charges.","estimated_amount":19.35,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_percentage":17.10,"standard_charge_algorithm":"Reimbursement will be 17.1% of billable gross charges.","estimated_amount":15.99,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":17.77,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":17.77,"methodology":"percent of total billed charges"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_percentage":21.00,"standard_charge_algorithm":"Reimbursement will be 21% of billable gross charges.","estimated_amount":19.64,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":6.54,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":6.54,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":6.54,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":6.54,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":6.54,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":74.80,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":42.08,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":17.30,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"SYNCOPE AND COLLAPSE ","code_information":[{"code":"312","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3948.00,"maximum":13879.85,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":8838.33,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":9402.48,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":12310.44,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":11989.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10624.00,"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":8954.74,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":8954.74,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":10829.29,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11200.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":8865.19,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":8865.19,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":8865.19,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":8865.19,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":8865.19,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":12984.37,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":9133.83,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":11599.62,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":9801.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":12781.97,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":8677.14,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":8677.14,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":12781.97,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":9492.02,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":8954.74,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":12447.09,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":12042.24,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":9241.01,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":8775.65,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":7700.55,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":9402.48,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":9133.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":9133.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":9133.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":9133.83,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":9133.83,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":9581.57,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":13879.85,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":13879.85,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":13879.85,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":9402.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":9402.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":9402.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":9402.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":9402.48,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":9402.48,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":9223.38,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":8954.74,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6145.00,"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":8739.83,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6140.00,"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":3948.00,"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":9044.29,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":9850.21,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":9223.38,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":9223.38,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":9223.38,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":9223.38,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":9223.38,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":8865.19,"methodology":"fee schedule"}]}]},{"description":"SYRINGE ANGIO INFL 30ML ","code_information":[{"code":"100361","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":1594.00,"discounted_cash":1594.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":709.33,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":709.33,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":709.33,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":559.49,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":559.49,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":559.49,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_percentage":6.63,"standard_charge_algorithm":"Reimbursement will be 6.63% of billable gross charges.","estimated_amount":105.68,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":518.05,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":518.05,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":518.05,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":656.73,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":656.73,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":656.73,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":479.79,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":446.32,"methodology":"percent of total billed 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If billable gross charges exceed threshold of $563855.00, reimbursement will be $6495 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13601.05,"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":14074.85,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15329.05,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":14353.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":14353.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":14353.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":14353.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":14353.57,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":13796.15,"methodology":"fee schedule"}]}]},{"description":"Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, free standing, complete with grab bar ","code_information":[{"code":"E0912","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":94.66,"maximum":198.01,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":97.41,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":101.42,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":96.59,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":96.59,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":96.59,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":96.59,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":96.59,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":96.59,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":96.59,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":96.59,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":140.06,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":96.59,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":96.59,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":96.59,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":99.49,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":134.26,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":198.01,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":94.66,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":101.42,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":102.39,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":102.39,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":102.39,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":102.39,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":102.39,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":101.42,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":149.71,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":149.71,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":140.06,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":101.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":101.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":101.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":101.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":101.42,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":101.42,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":96.59,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":97.07,"methodology":"fee schedule"},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":97.56,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":125.57,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":99.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":99.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":99.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":99.49,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":99.49,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":97.07,"methodology":"fee schedule"}]}]},{"description":"TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":18707.11,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":11989.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10624.00,"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":12197.91,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":12197.91,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":16456.34,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17019.67,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":12075.93,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":12075.93,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":12075.93,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":12075.93,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":12075.93,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":17686.97,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":12441.87,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":17461.33,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":14754.19,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":19241.17,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":11819.77,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":11819.77,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":19241.17,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":12929.78,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":12197.91,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":16955.09,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":18127.62,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":13910.83,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":11953.95,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":11591.92,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":12807.81,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":12441.87,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":12441.87,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":12441.87,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":12441.87,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":12441.87,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13051.76,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":18906.76,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":18906.76,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":18906.76,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":12807.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":12807.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":12807.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":12807.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":12807.81,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":12807.81,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":12563.85,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":12197.91,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6145.00,"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":11905.16,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6140.00,"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":3948.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":12319.89,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":13417.70,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":12563.85,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":12563.85,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":12563.85,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":12563.85,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":12563.85,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":12075.93,"methodology":"fee schedule"}]}]},{"description":"TRAY BX 105MM 12GA 10GA ","code_information":[{"code":"621817","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":4973.00,"discounted_cash":4973.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":2212.99,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":2212.99,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":2212.99,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":1745.52,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":1745.52,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":1745.52,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_percentage":6.63,"standard_charge_algorithm":"Reimbursement will be 6.63% of billable gross charges.","estimated_amount":329.71,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":1616.22,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":1616.22,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":1616.22,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":2048.88,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":2048.88,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":2048.88,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":1496.87,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":1392.44,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":1486.93,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":1501.85,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":1332.76,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":1879.79,"methodology":"percent of total billed charges"},{"payer_name":"Christus 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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":"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":34817.23,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":34817.23,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":34817.23,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":34817.23,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":34817.23,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":50994.93,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":35872.30,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":58979.25,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":49835.32,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":64991.03,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":34078.68,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":34078.68,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":64991.03,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":37279.06,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":35168.92,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":48884.80,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":61229.79,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":46986.70,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":34465.54,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":39154.11,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":36927.37,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 9. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":35872.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":35872.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":35872.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":35872.30,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":35872.30,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":37630.74,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":54511.83,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":54511.83,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":54511.83,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":36927.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":36927.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":36927.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":36927.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":36927.37,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":36927.37,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":36223.99,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":35168.92,"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":34324.87,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":9880.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":11500.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $6148 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":22.40,"standard_charge_algorithm":"Reimbursement will be 22.4% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"SmallGroup","standard_charge_dollar":9330.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":35520.61,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":38685.81,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":36223.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":36223.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":36223.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":36223.99,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":36223.99,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":34817.23,"methodology":"fee schedule"}]}]},{"description":"Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad ","code_information":[{"code":"L6050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2643.25,"maximum":21669.94,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":2720.12,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":2832.05,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":2697.19,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":2697.19,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":2697.19,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":2697.19,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":2697.19,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":2697.19,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":2697.19,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":2697.19,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":3910.93,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":2697.19,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":21669.94,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":2697.19,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":2697.19,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":21669.94,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":2778.11,"methodology":"fee schedule"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":3749.09,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":5529.24,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":2643.25,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":2832.05,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":2859.02,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":2859.02,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":2859.02,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":2859.02,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":2859.02,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":2832.05,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":4180.64,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":4180.64,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":3910.93,"methodology":"fee schedule"},{"payer_name":"Superior Health 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","code_information":[{"code":"103752","type":"CDM"},{"code":"L3809","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":263.82,"maximum":2162.86,"gross_charge":475.00,"discounted_cash":475.00,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":271.49,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":282.66,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCR","standard_charge_dollar":269.20,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":269.20,"methodology":"fee schedule"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_dollar":269.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":269.20,"methodology":"fee schedule"},{"payer_name":"Cigna 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least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, H ","code_information":[{"code":"81470","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":895.72,"maximum":5716.89,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_dollar":5716.89,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_dollar":5716.89,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_dollar":5716.89,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_dollar":4501.27,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_dollar":4501.27,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_dollar":4501.27,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":921.77,"methodology":"fee 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charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":106.59,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":106.59,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":106.59,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross 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charges.","estimated_amount":151.69,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"AA 5/D15 ELECT 1000ML ","code_information":[{"code":"803000","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":917.45,"discounted_cash":917.45,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":408.27,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":408.27,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":408.27,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":322.02,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":322.02,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":322.02,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_percentage":6.63,"standard_charge_algorithm":"Reimbursement will be 6.63% of billable gross charges.","estimated_amount":60.83,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":298.17,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":298.17,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":298.17,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":377.99,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":377.99,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":377.99,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":276.15,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":256.89,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":274.32,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":277.07,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":245.88,"methodology":"percent of total billed 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total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":284.41,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":119.27,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":119.27,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross 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gross charges.","estimated_amount":412.85,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":169.73,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"ABORTION WITHOUT D&C ","code_information":[{"code":"779","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3948.00,"maximum":15544.00,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":9299.25,"methodology":"fee schedule"},{"payer_name":"American Health Plan","plan_name":"MCR","standard_charge_dollar":9892.82,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":15544.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":11989.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10624.00,"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":9421.73,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":9421.73,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":13673.81,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14141.89,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":9327.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":9327.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":9327.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":9327.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":9327.52,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":13661.51,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":9610.17,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":12443.66,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":10514.44,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":13712.05,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":9129.66,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":9129.66,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":13712.05,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":9987.04,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":9421.73,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":13096.21,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":12918.49,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":9913.43,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":9233.30,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":8260.88,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":9892.82,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":9610.17,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":9610.17,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":9610.17,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":9610.17,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":9610.17,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":10081.25,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":14603.69,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":14603.69,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":14603.69,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":9892.82,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":9892.82,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":9892.82,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":9892.82,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":9892.82,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":9892.82,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":9704.38,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":9421.73,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6145.00,"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":9195.61,"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":6140.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  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Texas","plan_name":"PPO","standard_charge_dollar":50.49,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":50.49,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":50.01,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":73.83,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":73.83,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":69.06,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":50.01,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":50.01,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":50.01,"methodology":"fee 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schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":49.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":49.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":49.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":49.06,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":49.06,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":47.87,"methodology":"fee schedule"}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC ","code_information":[{"code":"280","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8010.00,"maximum":24080.81,"payers_information":[{"payer_name":"Aetna","plan_name":"MCR","standard_charge_dollar":14437.73,"methodology":"fee schedule"},{"payer_name":"American 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":23586.08,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":11989.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10624.00,"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":14627.89,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":14627.89,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":20748.29,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":21458.54,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":15936.45,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":16102.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 5. 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"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_dollar":12485.00,"methodology":"fee schedule","additional_payer_notes":" If billable gross charges exceed threshold of $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11159.00,"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":26070.67,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":26070.67,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4779.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":5175.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6156.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":25809.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":25809.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":25809.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":25809.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":25809.96,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":37802.47,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":26592.08,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":42535.03,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":35940.56,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":46870.65,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":25262.48,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":25262.48,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":46870.65,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":27634.91,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":26070.67,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":36238.23,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":44158.10,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":33886.17,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":25549.26,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":28237.41,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":27374.20,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":26592.08,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":26592.08,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":26592.08,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":26592.08,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":26592.08,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":27895.62,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"EPO","standard_charge_dollar":40409.54,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"HMO","standard_charge_dollar":40409.54,"methodology":"fee schedule"},{"payer_name":"Superior","plan_name":"ValueHMO","standard_charge_dollar":40409.54,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":27374.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":27374.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":27374.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":27374.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":27374.20,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":27374.20,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":26852.79,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":26070.67,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11545.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  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If billable gross charges exceed threshold of $563855.00, reimbursement will be $4501 per diem instead of the contracted rate."},{"payer_name":"Van Lang IPA","plan_name":"MCR","standard_charge_dollar":26331.38,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":28677.74,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":26852.79,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":26852.79,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":26852.79,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":26852.79,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":26852.79,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":25809.96,"methodology":"fee 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"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_dollar":1193.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $454276.00, reimbursement will be the lesser of (a) 24% of billable gross charges, or (b) $6015 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 $525268.00, reimbursement will be the lesser of (a) 25% of billable gross charges, or (b) $10125 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1215.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $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":9270.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MGMCRHMO","standard_charge_dollar":9270.00,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_dollar":1009.00,"methodology":"per diem","additional_payer_notes":" If billable gross charges exceed threshold of $386135.00, reimbursement will be the lesser of (a) 20.4% of billable gross charges, or (b) $5401 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 $525268.00, reimbursement will be the lesser of (a) 26.6% of billable gross charges, or (b) $11010 multiplied by the number of medically necessary days."},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":999999999.00,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_dollar":4523.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_dollar":4899.00,"methodology":"per diem"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5828.00,"methodology":"per diem"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":9177.30,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRPPO","standard_charge_dollar":9177.30,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MCRSNP","standard_charge_dollar":9177.30,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MMP","standard_charge_dollar":9177.30,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"PFFS","standard_charge_dollar":9177.30,"methodology":"fee schedule"},{"payer_name":"Community Health Choice","plan_name":"HIX","standard_charge_dollar":13441.50,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MGMCR","standard_charge_dollar":9455.40,"methodology":"fee schedule"},{"payer_name":"Evry Health","plan_name":"BroadNetwork","standard_charge_dollar":12169.41,"methodology":"fee schedule"},{"payer_name":"Healthcare Highways","plan_name":"NarrowNetwork","standard_charge_dollar":10282.71,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"HMO","standard_charge_dollar":13409.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantageHMO","standard_charge_dollar":8982.63,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MedicareAdvantagePPOPFFS","standard_charge_dollar":8982.63,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"PPO","standard_charge_dollar":13409.85,"methodology":"fee schedule"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_dollar":9826.20,"methodology":"fee schedule"},{"payer_name":"Integranet Amerigroup IPA","plan_name":"MCR","standard_charge_dollar":9270.00,"methodology":"fee schedule"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_dollar":10579.00,"methodology":"per diem"},{"payer_name":"Molina","plan_name":"MGMCR","standard_charge_dollar":12885.30,"methodology":"fee schedule"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_dollar":12633.78,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_dollar":9694.94,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"MGMCR","standard_charge_dollar":9084.60,"methodology":"fee schedule"},{"payer_name":"Oscar","plan_name":"NARROW","standard_charge_dollar":8078.82,"methodology":"fee schedule"},{"payer_name":"ProCare Advantage","plan_name":"MGMCR","standard_charge_dollar":9733.50,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"MCRHMO","standard_charge_dollar":9455.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PFFS","standard_charge_dollar":9455.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"POS","standard_charge_dollar":9455.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"PPO","standard_charge_dollar":9455.40,"methodology":"fee schedule"},{"payer_name":"Provider Partners Health Plan of Texas","plan_name":"SNP","standard_charge_dollar":9455.40,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":9918.90,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"DualEligible","standard_charge_dollar":9733.50,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRHMO","standard_charge_dollar":9733.50,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPOS","standard_charge_dollar":9733.50,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRPPO","standard_charge_dollar":9733.50,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"MCRSNP","standard_charge_dollar":9733.50,"methodology":"fee schedule"},{"payer_name":"Superior Health Plan","plan_name":"PFFS","standard_charge_dollar":9733.50,"methodology":"fee schedule"},{"payer_name":"Texas Independent Health Plan","plan_name":"MCR","standard_charge_dollar":9548.10,"methodology":"fee schedule"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_dollar":9270.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6145.00,"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":9047.52,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"NarrowNetworkIndivExchange","standard_charge_dollar":4515.00,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $562458.00, reimbursement will be $4564 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"NationalAccount","standard_charge_dollar":6140.00,"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":3948.00,"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":9362.70,"methodology":"fee schedule"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":10197.00,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"MCRHMO","standard_charge_dollar":9548.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PFFS","standard_charge_dollar":9548.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"POS","standard_charge_dollar":9548.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"PPO","standard_charge_dollar":9548.10,"methodology":"fee schedule"},{"payer_name":"WellCare","plan_name":"SNP","standard_charge_dollar":9548.10,"methodology":"fee schedule"},{"payer_name":"WellMed","plan_name":"MGMCR","standard_charge_dollar":9177.30,"methodology":"fee schedule"}]}]},{"description":"DEVICE BALLOON INFLATION ","code_information":[{"code":"109122","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":2201.00,"discounted_cash":2201.00,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":979.45,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":979.45,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":979.45,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":772.55,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":772.55,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":772.55,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_percentage":6.63,"standard_charge_algorithm":"Reimbursement will be 6.63% of billable gross charges.","estimated_amount":145.93,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":715.33,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":715.33,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":715.33,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONHMO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":906.81,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPOS","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":906.81,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"OONPPO","standard_charge_percentage":41.20,"standard_charge_algorithm":"Reimbursement will be 41.2% of billable gross charges.","estimated_amount":906.81,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"BAV","standard_charge_percentage":30.10,"standard_charge_algorithm":"Reimbursement will be 30.1% of billable gross charges.","estimated_amount":662.50,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"EPOSOA","standard_charge_percentage":28.00,"standard_charge_algorithm":"Reimbursement will be 28% of billable gross charges.","estimated_amount":616.28,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_percentage":29.90,"standard_charge_algorithm":"Reimbursement will be 29.9% of billable gross charges.","estimated_amount":658.10,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"MyBlueHealth","standard_charge_percentage":30.20,"standard_charge_algorithm":"Reimbursement will be 30.2% of billable gross charges.","estimated_amount":664.70,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_percentage":26.80,"standard_charge_algorithm":"Reimbursement will be 26.8% of billable gross charges.","estimated_amount":589.87,"methodology":"percent of total billed charges"},{"payer_name":"BCBS","plan_name":"Traditional","standard_charge_percentage":37.80,"standard_charge_algorithm":"Reimbursement will be 37.8% of billable gross charges.","estimated_amount":831.98,"methodology":"percent of total billed charges"},{"payer_name":"Christus (USFHP)","plan_name":"TRICARE","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","estimated_amount":880.40,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"CSN","standard_charge_percentage":24.00,"standard_charge_algorithm":"Reimbursement will be 24% of billable gross charges not to exceed $8633.","estimated_amount":528.24,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"OpenAccessPlus","standard_charge_percentage":26.10,"standard_charge_algorithm":"Reimbursement will be 26.1% of billable gross charges not to exceed $9351.","estimated_amount":574.46,"methodology":"percent of total billed charges"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":31.00,"standard_charge_algorithm":"Reimbursement will be 31% of billable gross charges not to exceed $11123.","estimated_amount":682.31,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIP","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":286.13,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"CHIPPerinatal","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":286.13,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross charges.","estimated_amount":286.13,"methodology":"percent of total billed charges"},{"payer_name":"Community Health Choice MCD","plan_name":"STAR+PLUS","standard_charge_percentage":13.00,"standard_charge_algorithm":"Reimbursement will be 13% of billable gross 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charges.","estimated_amount":702.34,"methodology":"percent of total billed charges"},{"payer_name":"Imperial Insurance Co","plan_name":"MCR","standard_charge_percentage":19.00,"standard_charge_algorithm":"Reimbursement will be 19% of billable gross charges.","estimated_amount":418.19,"methodology":"percent of total billed charges"},{"payer_name":"Kelsey Seybold","plan_name":"MCR","standard_charge_percentage":35.00,"standard_charge_algorithm":"Reimbursement will be 35% of billable gross charges.","estimated_amount":770.35,"methodology":"percent of total billed charges"},{"payer_name":"Molina Healthcare","plan_name":"HIX","standard_charge_percentage":27.00,"standard_charge_algorithm":"Reimbursement will be 27% of billable gross charges.","estimated_amount":594.27,"methodology":"percent of total billed charges"},{"payer_name":"Oscar","plan_name":"BROAD","standard_charge_percentage":20.70,"standard_charge_algorithm":"Reimbursement will be 20.7% of billable gross 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charges.","estimated_amount":462.21,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"CHIP","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":154.07,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"CHPFC","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":154.07,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STAR","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":154.07,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STARKids","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":154.07,"methodology":"percent of total billed charges"},{"payer_name":"Superior Health Plan","plan_name":"STARPLUS","standard_charge_percentage":7.00,"standard_charge_algorithm":"Reimbursement will be 7% of billable gross charges.","estimated_amount":154.07,"methodology":"percent of total billed charges"},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Veterans","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":1760.80,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"GlobalAppendix","standard_charge_percentage":45.00,"standard_charge_algorithm":"Reimbursement will be 45% of billable gross charges.","estimated_amount":990.45,"methodology":"percent of total billed charges"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":18.50,"standard_charge_algorithm":"Reimbursement will be 18.5% of billable gross charges.","estimated_amount":407.19,"methodology":"percent of total billed charges"},{"payer_name":"Verda Health Plan","plan_name":"MCR","standard_charge_dollar":15000.00,"methodology":"case rate"}]}]},{"description":"DEVICE CLS WND +4-0 45CM ","code_information":[{"code":"620196","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":15000.00,"maximum":15000.00,"gross_charge":1541.50,"discounted_cash":1541.50,"payers_information":[{"payer_name":"Aetna","plan_name":"ASAHMO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":685.97,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPOS","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":685.97,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"ASAPPO","standard_charge_percentage":44.50,"standard_charge_algorithm":"Reimbursement will be 44.5% of billable gross charges.","estimated_amount":685.97,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMHMO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":541.07,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPOS","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":541.07,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"COMMPPO","standard_charge_percentage":35.10,"standard_charge_algorithm":"Reimbursement will be 35.1% of billable gross charges.","estimated_amount":541.07,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"MCR","standard_charge_percentage":6.63,"standard_charge_algorithm":"Reimbursement will be 6.63% of billable gross charges.","estimated_amount":102.20,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBHMO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":500.99,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPOS","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":500.99,"methodology":"percent of total billed charges"},{"payer_name":"Aetna","plan_name":"NBPPO","standard_charge_percentage":32.50,"standard_charge_algorithm":"Reimbursement will be 32.5% of billable gross charges.","estimated_amount":500.99,"methodology":"percent of total billed 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